Methods and Systems for Display of Patient Data in Computer-Assisted Surgery

ABSTRACT

Methods and systems for performing computer-assisted image-guided surgery, including robotically-assisted surgery. A method of displaying image data includes displaying image data of a patient on a handheld display device, tracking the handheld display device using a motion tracking system, and modifying the image data displayed in response to changes in the position and orientation of the handheld display device. Further embodiments include a sterile case for a handheld display device, display devices on a robotic arm, and methods and systems for performing image-guided surgery using multiple reference marker devices fixed to a patient.

RELATED APPLICATIONS

This application claims the benefit of priority to U.S. ProvisionalApplication No. 62/385,552, filed Sep. 9, 2016, the entire contents ofwhich are incorporated by reference herein.

BACKGROUND

Computer-assisted surgical procedures, which may include image guidedsurgery and robotic surgery, have attracted increased interest in recentyears. These procedures include the integration of a “virtual”three-dimensional dataset of the patient's anatomy, typically obtainedusing pre-operative or intra-operative medical imaging (e.g., x-raycomputed tomography (CT) or magnetic resonance (MR) imaging), to theactual position of the patient and/or other objects (e.g., surgicalinstruments, robotic manipulator(s) or end effector(s) in the surgicalarea. These procedures may be used to aid the surgeon in planning asurgical procedure and may also provide the surgeon with relevantfeedback during the course of surgical procedure. There is a continuingneed to improve the safety and ease-of-use of computer-assisted surgicalsystems.

SUMMARY

Various embodiments include methods and systems for performingcomputer-assisted image-guided surgery, including robotically-assistedsurgery.

Embodiments include methods of displaying image data that includedisplaying image data of a patient on a display screen of a handhelddisplay device, tracking at least one of a position and an orientationof the handheld display device with respect to the patient, andmodifying at least a portion of the image data displayed on the displayscreen in response to a change in at least one of the position andorientation of the handheld display device with respect to the patient.

Further embodiments include methods of displaying image data thatinclude displaying image data of a patient on a display screen, trackingat least one of a position and an orientation of an end effector of arobotic arm with respect to the patient, and modifying at least aportion of the image data displayed on the display screen in response toa change in at least one of the position and orientation of the endeffector with respect to the patient.

Further embodiments include a sterile case for a handheld display devicethat includes a first portion defining a first surface of the case, thefirst portion having a window region in the first surface that is sizedand shaped to correspond to a display screen of a handheld displaydevice, a second portion defining a second surface of the case oppositethe first surface, the first portion and the second portion defining ahousing for receiving a handheld display device, the first and secondportions having corresponding mating features that are engaged to securea handheld display device within the housing, and a plurality of markersmounted to at least one of the first portion and the second portion anddisposed in a pre-determined geometric pattern to enable at least one ofthe position and the orientation of the case to be tracked by a motiontracking system, the first portion and the second portion havingsufficient rigidity to prevent relative movement of the plurality ofmarkers.

Further embodiments include a display device for a robotic arm thatincludes a contoured viewing surface that extends around at least 50% ofan outer periphery of a linkage member of the robotic arm, the displaydevice displaying image data of a patient on the viewing surface.

Further embodiments include a robotic arm having a plurality of displaydevices mounted to different locations on the arm, wherein each displaydevice may selectively display different indicators to indicate whethera particular portion of the arm may be moved in a handguided mode.

Further embodiments include a robotic arm having at least one displaydevice located on a portion of the arm, wherein the at least one displaydevice is configured to provide an indication of a direction in whichthe portion of the robotic arm may be moved in a handguided mode.

Further embodiments include methods for performing image-guided surgeryusing multiple reference marker devices fixed to a patient, the methodsincluding obtaining patient images using an imaging device, registeringat least a first portion of the patient images in a first patientcoordinate system associated with first reference marker device fixed toa first location on the patient, registering at least a second portionof the patient images to a second patient coordinate system associatedwith a second reference marker device fixed to a second location on thepatient, and selecting between display of patient images registered tothe first patient coordinate system and display of patient imagesregistered to the second patient coordinate system in an image guidedsurgery system based on a proximity to the first and second locations.

Further embodiments include methods for performing image-guided surgeryusing multiple reference marker devices fixed to a patient, the methodsincluding obtaining patient images using an imaging device, tracking afirst reference marker device fixed to a first location on the patientand a second reference marker device fixed to a second location on thepatient using a motion tracking system, and displaying one or morepatient images corresponding to a third location on the patient and agraphical depiction of a pose of an object tracked by the motiontracking system based on tracking data for both the first referencemarker device and the second reference marker device in an image-guidedsurgery system.

Further embodiments include methods for performing image-guided surgeryusing multiple reference marker devices fixed to a patient, the methodsincluding obtaining patient images using an imaging device, registeringpatient images to a patient coordinate system, displaying the patientimages and a graphical depiction of a pose of an object tracked by amotion tracking system in the patient coordinate system using animage-guided surgery system, detecting a relative motion between a firstreference marker device fixed to a first location on the patient and asecond reference marker device fixed to a second location on the patientusing the motion tracking system, determining whether the detectedrelative motion is consistent with an anatomic movement, and updatingthe display of the patient images and the graphical depiction of thepose of the object based on an estimation of the anatomic movement inresponse to determining that the detected relative motion is consistentwith an anatomic movement.

Further embodiments include an image guided surgery system including aplurality of minimally-invasive reference markers fixed to differentlocations within a patient.

BRIEF DESCRIPTION OF THE DRAWINGS

Other features and advantages of the present invention will be apparentfrom the following detailed description of the invention, taken inconjunction with the accompanying drawings of which:

FIG. 1 is a perspective view of a system for performingrobotically-assisted image-guided surgery according to an embodiment.

FIG. 2 shows an alternative embodiment of a system for performingrobotically-assisted image-guided surgery having an optical sensingdevice for a motion tracking system on an arm extending from a gantry ofan imaging system.

FIG. 3 is a process flow diagram illustrating a method for performingregistration of patient image data for image-guided surgery.

FIG. 4 is a block diagram schematically illustrating a system forimage-guided surgery according to an embodiment.

FIG. 5 illustrates a display screen of a display device in animage-guided surgery system according to an embodiment.

FIGS. 6A-6C schematically illustrate methods of displaying patientimages in an image-guided surgery system based on a detected positionand/or orientation of an end effector of a robotic arm according to anembodiment.

FIGS. 7A-7F schematically illustrate methods of displaying patientimages in an image-guided surgery system based on a detected positionand/or orientation of a handheld display device according to anembodiment.

FIGS. 8A-8F illustrate a sterile case for a handheld display deviceaccording to an embodiment.

FIG. 9 illustrates a robotic arm having a display device on the roboticarm according to an embodiment.

FIG. 10A is a cross-section side view of a spine of a patient having aplurality of reference marker devices attached thereto.

FIG. 10B illustrates a minimally-invasive reference marker deviceaccording to an embodiment.

FIG. 11A is a process flow diagram illustrating a method of performingimage-guided surgery using multiple reference marker devices fixed to apatient.

FIG. 11B is a process flow diagram illustrating a further embodimentmethod of performing image-guided surgery using multiple referencemarker devices fixed to a patient.

FIG. 11C is a process flow diagram illustrating a further embodimentmethod of performing image-guided surgery using multiple referencemarker devices fixed to a patient

FIG. 12 schematically illustrate a computing device which may be usedfor performing various embodiments.

DETAILED DESCRIPTION

The various embodiments will be described in detail with reference tothe accompanying drawings. Wherever possible, the same reference numberswill be used throughout the drawings to refer to the same or like parts.References made to particular examples and implementations are forillustrative purposes, and are not intended to limit the scope of theinvention or the claims.

FIG. 1 illustrates a system 100 for performing computer-assistedimage-guided surgery according to various embodiments. The system 100 inthis embodiment includes an imaging device 103, a motion tracking system105 and a robotic arm 101 for performing a robotically-assisted surgicalprocedure. The robotic arm 101 may comprise a multi joint arm thatincludes a plurality of linkages connected by joints having actuator(s)and optional encoder(s) to enable the linkages to rotate, bend and/ortranslate relative to one another in response to control signals from arobot control system. The robotic arm 101 may be fixed to a supportstructure at one end and may have an end effector 102 at the other endof the robotic arm 101.

The imaging device 103 may be used to obtain diagnostic images of apatient 200, which may be a human or animal patient. In embodiments, theimaging device 103 may be an x-ray computed tomography (CT) imagingdevice. The patient 200 may be positioned within a central bore 107 ofthe imaging device 103 and an x-ray source and detector may be rotatedaround the bore 107 to obtain x-ray image data (e.g., raw x-rayprojection data) of the patient 200. The collected image data may beprocessed using a suitable processor (e.g., computer) to perform athree-dimensional reconstruction of the object. In other embodiments,the imaging device 103 may comprise one or more of an x-ray fluoroscopicimaging device, a magnetic resonance (MR) imaging device, a positronemission tomography (PET) imaging device, a single-photon emissioncomputed tomography (SPECT), or an ultrasound imaging device. Inembodiments, image data may be obtained pre-operatively (i.e., prior toperforming a surgical procedure), intra-operatively (i.e., during asurgical procedure) or post-operative (i.e., following a surgicalprocedure) by positioning the patient 200 within the bore 107 of theimaging device 103. In the system 100 of FIG. 1, this may beaccomplished by moving the imaging device 103 over the patient 200 toperform a scan while the patient 200 may remain stationary.

Examples of x-ray CT imaging devices that may be used according tovarious embodiments are described in, for example, U.S. Pat. No.8,118,488, U.S. Patent Application Publication No. 2014/0139215, U.S.Patent Application Publication No. 2014/0003572, U.S. Patent ApplicationPublication No. 2014/0265182 and U.S. Patent Application Publication No.2014/0275953, the entire contents of all of which are incorporatedherein by reference. In the embodiment shown in FIG. 1, the patientsupport 60 (e.g., surgical table) upon which the patient 200 may belocated is secured to the imaging device 103, such as via a column 50which is mounted to a base 20 of the imaging device 103. A portion ofthe imaging device 103 (e.g., an O-shaped imaging gantry 40) whichincludes at least one imaging component may translate along the lengthof the base 20 on rails 23 to perform an imaging scan of the patient200, and may translate away from the patient 200 to an out-of-the-waypositon for performing a surgical procedure on the patient 200.

An example imaging device 103 that may be used in various embodiments isthe AIRO® intra-operative CT system manufactured by Mobius Imaging, LLCand distributed by Brainlab, AG. Other imaging devices may also beutilized. For example, the imaging device 103 may be a mobile CT devicethat is not attached to the patient support 60 and may be wheeled orotherwise moved over the patient 200 and the support 60 to perform ascan. Examples of mobile CT devices include the BodyTom® CT scanner fromSamsung Electronics Co., Ltd. and the O-Arm® surgical imaging systemform Medtronic, plc. The imaging device 103 may also be a C-arm x-rayfluoroscopy device. In other embodiments, the imaging device 103 may bea fixed-bore imaging device, and the patient 200 may be moved into thebore of the device, either on a surgical support 60 as shown in FIG. 1,or on a separate patient table that is configured to slide in and out ofthe bore. Further, although the imaging device 103 shown in FIG. 1 islocated close to the patient 200 within the surgical theater, theimaging device 103 may be located remote from the surgical theater, suchas in another room or building (e.g., in a hospital radiologydepartment).

The motion tracking system 105 shown in FIG. 1 includes a plurality ofmarker devices 119, 202, 115 and an optical sensor device 111. Varioussystems and technologies exist for tracking the position (includinglocation and/or orientation) of objects as they move within athree-dimensional space. Such systems may include a plurality of activeor passive markers fixed to the object(s) to be tracked and a sensingdevice that detects radiation emitted by or reflected from the markers.A 3D model of the space may be constructed in software based on thesignals detected by the sensing device.

The motion tracking system 105 in the embodiment of FIG. 1 includes aplurality of marker devices 119, 202 and 315 and a stereoscopic opticalsensor device 111 that includes two or more cameras (e.g., IR cameras).The optical sensor device 111 may include one or more radiation sources(e.g., diode ring(s)) that direct radiation (e.g., IR radiation) intothe surgical field, where the radiation may be reflected by the markerdevices 119, 202 and 315 and received by the cameras. The marker devices119, 202, 315 may each include three or more (e.g., four) reflectingspheres, which the motion tracking system 105 may use to construct acoordinate system for each of the marker devices 119, 202 and 315. Acomputer 113 may be coupled to the sensor device 111 and may determinethe transformations between each of the marker devices 119, 202, 115 andthe cameras using, for example, triangulation techniques. A 3D model ofthe surgical space in a common coordinate system may be generated andcontinually updated using motion tracking software implemented by thecomputer 113. In embodiments, the computer 113 may also receive imagedata from the imaging device 103 and may register the image data to thecommon coordinate system as the motion tracking system 105 using imageregistration techniques as are known in the art. In embodiments, areference marker device 115 (e.g., reference arc) may be rigidlyattached to a landmark in the anatomical region of interest (e.g.,clamped or otherwise attached to a bony portion of the patient'sanatomy) to enable the anatomical region of interest to be continuallytracked by the motion tracking system 105. Additional marker devices 119may be attached to surgical tools 104 to enable the tools 104 to betracked within the common coordinate system. Another marker device 202may be rigidly attached to the robotic arm 101, such as on the endeffector 102 of the robotic arm 101, to enable the position of roboticarm 101 and end effector 102 to be tracked using the motion trackingsystem 105. The computer 113 may also include software configured toperform a transform between the joint coordinates of the robotic arm 101and the common coordinate system of the motion tracking system 105,which may enable the position and orientation of the end effector 102 ofthe robotic arm 101 to be controlled with respect to the patient 200.

In addition to passive marker devices described above, the motiontracking system 105 may alternately utilize active marker devices thatmay include radiation emitters (e.g., LEDs) that may emit radiation thatis detected by an optical sensor device 111. Each active marker deviceor sets of active marker devices attached to a particular object mayemit radiation in a pre-determined strobe pattern (e.g., with modulatedpulse width, pulse rate, time slot and/or amplitude) and/or wavelengthwhich may enable different objects to be uniquely identified and trackedby the motion tracking system 105. One or more active marker devices maybe fixed relative to the patient, such as secured to the patient's skinvia an adhesive membrane or mask. Additional active marker devices maybe fixed to surgical tools 104 and/or to the end effector 102 of therobotic arm 101 to allow these objects to be tracked relative to thepatient.

In further embodiments, the marker devices may be passive maker devicesthat include moiré patterns that may enable their position andorientation to be tracked in three-dimensional space using a singlecamera using Moiré Phase Tracking (MPT) technology. Each moiré patternmarker may also include a unique identifier or code that may enabledifferent objects within the camera's field of view to be uniquelyidentified and tracked. An example of an MPT-based tracking system isavailable from Metria Innovation Inc. of Milwaukee, Wis. Other trackingtechnologies, such as computer vision systems and/or magnetic-basedtracking systems, may also be utilized.

FIG. 2 illustrates an alternative embodiment in which the optical sensordevice 111 includes a plurality of cameras 207 mounted to an arm 209extending above the patient 200 surgical area. The arm 209 may bemounted to the imaging device 103 and may extend/retract in atelescoping manner to adjust the position of the sensor device 111. Thearm 209 may also enable the sensor device 111 to pivot with respect tothe arm 209 and/or the imaging device 103 (e.g., via one or more balljoints 213). The arm 209 may enable a user to adjust the position of thesensor device 111 to provide the cameras 207 with a clear view into thesurgical field while avoiding obstructions. The arm 209 may enable theposition and/or orientation of the sensor device 111 to be adjusted andthen locked in place during an imaging scan or surgical procedure. Thepositioning of the optical sensor device 111 on an arm 209 may alsoenable the cameras 207 to more easily view and track markers 211 thatmay be located on the imaging device 103, such as on the outer surfaceof the gantry 40, which may be used during automatic registration ofpatient images, as described further below.

The system 100 may also include a display device 121 as schematicallyillustrated in FIG. 1. The display device 121 may display image data ofthe patient's anatomy obtained by the imaging device 103. The displaydevice 121 may facilitate planning for a surgical procedure, such as byenabling a surgeon to define one or more target positions in thepatient's body and/or a path or trajectory into the patient's body forinserting surgical tool(s) to reach a target position while minimizingdamage to other tissue or organs of the patient. The position and/ororientation of one or more objects tracked by the motion tracking system105 may be shown on the display device 121, and may be shown overlayingthe image data. In the embodiment of FIG. 1, the display device 121 islocated on a mobile cart 120. A computer 113 for controlling theoperation of the display device 121 may also be housed within the cart120. In embodiments, the computer 113 may be coupled to the opticalsensor device 111 and may also perform all or a portion of theprocessing (e.g., tracking calculations) for the motion tracking system105. Alternatively, one or more separate computers may perform themotion tracking processing, and may send tracking data to computer 113on the cart 120 via a wired or wireless communication link. The one ormore separate computers for the motion tracking system 105 may belocated on the imaging system 103, for example.

As shown in FIGS. 1-2, the robotic arm 101 may be fixed to the imagingdevice 103, such as on a support element 215 (e.g., a curved rail) thatmay extend concentrically over the outer surface of the O-shaped gantry40 of the imaging device 103. In embodiments, an arm 209 to which theoptical sensing device 111 is mounted (see FIG. 2) may be mounted to thesame or a similar support element 215 (e.g., curved rail) as the roboticarm 101. In other embodiments, the robotic arm 101 may be secured to anyother portion of the imaging device 103, such as directly mounted to thegantry 40. Alternatively, the robotic arm 101 may be mounted to thepatient support 60 or column 50, to any of the wall, ceiling or floor inthe operating room, or to a separate cart. Although a single robotic arm101 is shown in FIGS. 1 and 2, it will be understood that two or morerobotic arms 101 may be utilized. In addition, various embodiments of acomputer-assisted surgical method or system may include image-guided ornavigation-supported surgery without the use of a robotic arm 101.

FIG. 3 is a process flow diagram that illustrates a method 300 ofregistering patient images. Computer-assisted surgery techniquesgenerally utilize a process of correlating a dataset representing aportion of the patient's anatomy that is to be operated on with theposition of the patient at the time of the surgical intervention. Theposition of the patient may be determined based on a second imagedataset which may include real-time camera image(s) from a motiontracking system 105 as described above. The correlation between thesedatasets may be accomplished computationally using software, and may bereferred to as “patient registration.” The registration method 300 ofFIG. 3 may be implemented using one or more computing devices, such ascomputer 113 shown in FIG. 1.

In block 301 of method 300, a first image dataset of the patient'sanatomy may be obtained using an imaging device, such as the imagingdevice 103 shown in FIGS. 1 and 2. The first image dataset may be athree-dimensional dataset (e.g., a 3D CT tomographic reconstruction, a3D MRI dataset, etc.) representing at least a portion of the patient'sanatomy, including the internal anatomy and/or structure(s) that are tobe operated on (i.e., a surgically-relevant portion of the patient'sanatomy). The first image dataset may be stored electronically in amemory. The first image dataset may be in any suitable format, such asin a file format that conforms to the Digital Imaging and Communicationsin Medicine (DICOM) standard.

In block 303 of method 300, a second image dataset of the patient andthe surrounding patient space may be obtained using a motion trackingsystem, such as the motion tracking system 105 shown in FIGS. 1 and 2.The second image dataset may indicate the current position and/ororientation of the patient. The second image dataset may include atleast one image of a marker device that may be obtained using an opticalsensing device 111 (e.g., cameras 207). The marker device (e.g.,reference arc 115) detected by the optical sensing device 111 may be ina known fixed relationship with the surgically-relevant portion of thepatient's anatomy. The motion tracking system 105 may determine thetransformation between the marker device 115 and the optical sensingdevice 111 (e.g., using well-known triangulation techniques), and maythereby determine the transformation between the sensing device 111(e.g., camera 207 position) and the surgically-relevant portion of thepatient's anatomy. The motion tracking system 105 may similarlydetermine transformations between each of the other marker devices(e.g., marker devices 119 and 202 in FIG. 1) and the optical sensingdevice 111. Each of the markers 115, 119 and 202 being tracked may thenbe placed within a common coordinate system. In embodiments, the commoncoordinate system may have an origin or zero point that is fixedrelative to the surgically-relevant portion of the patient's anatomy,and may also be referred to the patient coordinate system.

In block 305 of method 300, the first image dataset may be registered tothe common coordinate system as the second image dataset (e.g., thepatient coordinate system). This may include performing a rigidtransformation to map each pixel or voxel of the first image datasetinto corresponding 3D coordinates (i.e., x, y, z coordinates) of thecommon coordinate system. A number of techniques may be utilized forregistering multiple image datasets. In one non-limiting example of aregistration process for x-ray CT imaging data, a pre-scan calibrationprocess may be used to precisely calculate (e.g., within 1 mm) thetransformation between the isocenter of the x-ray gantry 40 and theoptical sensing device 111. A set of markers 211 (e.g., 3 or more, suchas 4-6 markers) may be provided on the surface of the gantry 40, asshown in FIG. 2. The markers 211 may be within the field of view of theoptical sensing device 111 to enable the gantry 40 position to betracked by the motion tracking system 105. A calibration phantom (notshown for clarity) having a marker device (e.g., similar to markerdevice 115 in FIGS. 1 and 2) fixed thereto may be placed on the patientsupport 60 such that the marker device is also within the field of viewof the optical sensing device 111. The motion tracking system 105 maydetermine the transformation between the gantry 40 coordinate systemdefined by the markers 211 and the optical sensing device 111 coordinatesystem as well as the transformation between the phantom coordinatesystem defined by the marker device on the phantom and the opticalsensing device 111 coordinate system. These transformations may be usedto determine the gantry-to-phantom transformation. The phantom may thenbe scanned using the imaging device 103. A set of elements (e.g., x-rayvisible beads) that may be easily identified from the imaging data maybe located in the phantom, where the geometry of these elements withinthe phantom coordinate system may be previously-known. An algorithm maybe used to analyze the x-ray image data to identify the x-ray visibleelements with respect to the center point of the image data, whichcorresponds to the isocenter of the gantry 40. Thus, the x-ray visibleelements may be located in a coordinate system having an origin at theisocenter of the x-ray gantry 40, and the transformations between theisocenter and the phantom and the isocenter and the markers 211 on thegantry 40 may be calculated.

During a subsequent scan of the patient 200, the position andorientation of the patient 200 with respect to the isocenter of theimaging device 103 may be determined (i.e., by tracking the positions ofthe markers 211 on the gantry 40, which are known with respect to theisocenter, and the patient reference arc 115, which is known withrespect to the surgically-relevant portion of the patient anatomy). Thismay enable the image data obtained during the scan to be registered intothe patient coordinate system.

In an alternative embodiment, the position of the optical sensing device111 may be known relative to the imaging system 103 with sufficientaccuracy such that the image dataset of the patient's anatomy obtainedusing the imaging system 103 may be registered in the common coordinatesystem of the patient without the motion tracking system 105 needing totrack the position or orientation of the imaging system 103. Inembodiments, separate markers 211 on the gantry 40 of the imaging system103 as shown in FIG. 2 may not be required or used. In some embodiments,the position of the optical sensing device 111 (e.g., the position ofeach of the cameras 207 as shown in FIGS. 1 and 2) may be known relativeto the isocenter of the gantry 40 of the imaging system 103, such as viaa calibration process that may be performed at the factory or duringinstallation or pre-calibration of the system. The gantry 40 and/or theoptical sensing device 111 may include keying features (e.g.,high-precision bolt patterns) where the optical sensing device 111attaches to the gantry 40 to ensure that the position of the sensingdevice 111 on the gantry 40 remains accurately fixed. In embodimentswhere the camera(s) 207 may be movable relative to the gantry 40,high-precision encoders may precisely record and correct for any changesin camera position/orientation relative to the isocenter of the gantry40. During imaging scans, the optical sensing device 111 may track theposition and orientation of the patient 200 with respect to the cameraposition, which is in a known, fixed geometric relationship with theisocenter of the imaging device 103. The image data obtained during ascan may thus be registered into the common coordinate system of thepatient without needing to first perform a calibration scan on aphantom, as described above.

In block 307 of method 300, images of the patient's anatomy from thefirst image dataset may be displayed with an overlay of one or morefeatures derived from the second image dataset in the common coordinatesystem. The images may be displayed on a suitable display device, suchas display device 121 shown in FIG. 1. The images of the patient'sanatomy may include 2D slices of a three-dimensional image dataset(e.g., a tomographic reconstruction) and/or a 3D volume rendering of allor a portion of the image dataset. In embodiments, images obtained usingmultiple imaging devices or imaging modalities may be fused anddisplayed in a common coordinate system. For example, the first imagedataset of the patient's internal anatomy may be an x-ray CT scan.Another image dataset of the patient's internal anatomy, such as an MRIscan, may be combined with the x-ray CT data and displayed on thedisplay device 121. The MRI scan data may be registered into the commoncoordinate system using a similar registration process as describedabove. Alternately or in addition, an algorithm for matching landmarksor fiducials identifiable from both image datasets may be used to mergethe datasets for display.

The one or more features derived from the second image dataset that maybe displayed overlaying the images of the patient's anatomy may includegraphical depictions of a tool 104, an end effector 102 or anotherobject that is tracked by the motion tracking system 105. The graphicaldepiction may be based on a known geometry of the tool 104, end effector102 or other object. The graphical depiction may be a rendering of theactual size and shape of the object or may be a depiction of selectfeatures of the object, such as a location of a tip end of the objectand/or an orientation of the object. The graphical depiction may alsoindicate a trajectory defined by the object (e.g., a ray extending froma tip end of the object into the patient) and/or a target point withinthe patient's anatomy that may be defined based on the position and/ororientation of one or more objects being tracked. In variousembodiments, the tool 104 may be a pointer. The tool 104 may also be asurgical instrument, such as a needle, a cannula, a tool for gripping orcutting, an electrode, an implant, a drill bit, a screw, a screw driver,a radiation source, a drug and an endoscope. In embodiments, the endeffector 102 of the robotic arm 101 may include a hollow tube or cannulathat may be configured to hold one or more tools, such as a surgicalinstrument, and may be used to guide an instrument as it is insertedinto the patient's body. Alternately, the end effector 102 itself may beor may include an instrument that may be inserted into the patient'sbody.

The motion tracking system 105 may repeatedly acquire new images fromthe optical sensing device 111, and the relative positions and/ororientations of objects within the field of view of the optical sensingdevice 111 may be updated with each acquisition of new images from theoptical sensing device 111. The display device 121 may be updated toreflect any change(s) in the position and/or orientation of the objectswithin the common coordinate system (e.g., relative to the patientreference arc 115), which may include adding additional graphicalelements to depict new objects that are moved within the field of viewof the optical sensing device 111 and removing graphical depictions ofobjects when they are no longer within the field of view of the opticalsensing device 111. In some embodiments, the optical sensing device 111may include a motorized system to enable the position and/or orientationof the camera(s) 207 to move to maintain the surgical area within thecenter of the field of view of the camera(s) 207.

FIG. 4 is a component block diagram of an image-guided surgery system400 according to an embodiment. The system 400 may be implemented usingone or more computing devices, such as computer 113 shown in FIG. 1. Thesystem 400 may be operatively coupled to a first display device 121,which may include a monitor that is fixed to a cart 120 or otherstructure (e.g., wall, ceiling, floor, imaging device, etc.) within theoperating suite. The system 400 may also be operatively coupled to atleast one additional display device 401, which may be a handheldcomputing device, as described in further detail below. The system 400may also include an audio input/output component 403, which may includea speaker or other output component for outputting audible signals(e.g., audio instructions, alerts, etc.) and/or a microphone or otherinput component for receiving audio inputs (e.g., voice commands) thatmay be interpreted by the system 400. The system 400 may be implementedat least partially in software and may be based on one or more of theImage-Guided Surgery Toolkit (IGSTK), Visualization Toolkit (VTK) andInsight Segmentation and Registration Toolkit (ITK) developmentframeworks.

The system 400 may be configured to receive and store imaging data 407(e.g., DICOM data) collected by an imaging device 103. The imaging data407 may be received directly from the imaging device 103 or may beretrieved from another source, such as a remote server. The imaging data407 may be imaging data that is obtained prior to a surgical procedure(e.g., pre-operative image data) and/or imaging data that is obtainedduring a surgical procedure (e.g., intra-operative image data). Inembodiments, the system 400 may be configured to display themost-current image data 407 collected by the imaging device 103. Theimage data 407 may be registered to a common coordinate system as thetracking data 409 from the motion tracking system 105 in accordance witha registration method such as method 300 described above with referenceto FIG. 3.

The system 400 may also receive tracking data 409 from a motion trackingsystem 105. The system 400 may be configured to repeatedly read thetracking data from the motion tracking system 105 indicating the currentposition/orientation of the patient and any other objects tracked by themotion tracking system 105. The system 400 may read the tracking data ata frequency (e.g., refresh rate) of greater than 100 Hz (e.g., 240 Hz).In embodiments, the tracking data from the motion tracking system 105may include data to enable the system 400 to identify particular objectsfrom within the tracking data. For example, each marker device (e.g.,marker devices 115, 202 and 119 in FIG. 1) may include a uniquecharacteristic (e.g., a unique geometric pattern of reflective markers,a unique flash pattern of active markers, etc.) to enable the markerdevice to be identified. These unique characteristics of the markerdevices may be registered with particular objects or tools (e.g.,associated with a particular object or tool in a database) by the system400. The unique characteristics of the marker devices may bepre-registered in the system 400 and/or may be registered to particularobjects or tools during the course of a surgical procedure. The system400 may also include a library of graphical elements that may beassociated with particular objects or tools (e.g., in a database). Thesystem 400 may display graphical elements associated with the objects ortools being tracked by the motion tracking system 105 in the commoncoordinate system with the image data on the display(s) 121, 401.

The system 400 may include a user-interface component that may controlthe display of system information and/or graphical user interfaceelements on the display(s) 121 and 401. The system 400 may furtherprocess and implement user commands received from user interfacedevices. A user interface device, may include, for example, atouchscreen user interface which may be integrated with a display device121, 401. In embodiments, a user interface device may alternately oradditionally include one or more of a button, a keyboard, a joystick, amouse, a touchpad, etc. which may be located on a display device 121,401 and/or on a workstation (e.g., a workstation located on a cart 120).In embodiments, the user interface device(s) may also include amicrophone (e.g., audio input/output component 403) that may receivevoice commands that may be interpreted by the system (e.g., using voicerecognition software). The user commands received via one or more userinput devices may enable a user to control various functions of thesystem 400, such as changing what is shown on the display(s) 121, 401(e.g., displaying different image datasets, displaying differentslice(s) and/or different 3D rendering(s) within an image dataset,zooming in or out of an image, displaying different menu options,returning to a home screen, etc.). In embodiments, the user commands mayenable a user to set one or more trajectories and/or target locationswithin the patient's anatomy. The system 400 may store the positionsand/or orientations of user-defined trajectories or target locationswithin the common coordinate system, and may display graphicalrepresentations of such trajectories or target locations on thedisplay(s) 121, 401.

The user commands received by the system 400 may also include commandsfor controlling the operation of other components, such as the imagingdevice 103, the motion tracking system 105 and/or a robotic arm 101. Forexample, for a robotically-assisted surgical procedure, the user commandmay include an instruction to move a robotic arm 101 to a particularposition and/or orientation. The instruction to move the robotic arm 101may be based on a user interaction with image data of the patient'sanatomy that is displayed on a display device 121, 401. For example, theuser may use the display device 121, 401 to define a particulartrajectory with respect to the patient's anatomy and may send aninstruction for the robotic arm 101 to move such that that the endeffector 102 of the robotic arm 101 is positioned along the definedtrajectory.

A robotic control system 405 may control the movement of one or morerobotic arms 101. The robotic control system 405 may receive sensor dataindicating the current parameters of the robotic arm 101 (e.g., robotposition, joint angles, measured axis forces, motor currents) and maysend motor control signals to drive the movement of the arm 101. Inembodiments, the motion tracking system 105 may track the position ofthe robotic arm 101 (e.g., via marker device 202 on end effector 102 asshown in FIG. 1) to determine the position of the end effector 102within the common coordinate system of the patient. A control loop,which may be executed using the image-guided surgery system 400, themotion tracking system 105 and/or the robotic control system 405, maycontinuously read the tracking data and the robot parameter data and maysend instructions to the robotic control system 405 to cause the roboticarm 101 to move to a desired position and orientation.

In various embodiments, display device 121 may be a primary displaydevice (e.g., a monitor) that may be connected to the image-guidedsurgery system 400 by a wired or wireless link. In one embodiment, thesystem 400 may stream video data to the display device 121 over asuitable video data interface (e.g., an HDMI interface) and may alsoexchange other signals with the display device over a separate dataconnection (e.g., a USB connection).

In various embodiments, display device 401 may be a handheld computingdevice. As used herein, “handheld computing device” and “handhelddisplay device” are used interchangeably to refer to any one or all oftablet computers, smartphones, pendant controllers, cellular telephones,personal digital assistants (PDA's), netbooks, e-readers, laptopcomputers, palm-top computers, wearable computers, and similar portableelectronic devices which include a programmable processor and memorycoupled to a display screen and may include hardware and/or software toenable display of information, including patient information and/orimages, on the display screen. A handheld computing device typicallyalso includes an antenna coupled to circuitry (e.g., a transceiver) toenable wireless communication over a network. A handheld computing ordisplay device may be characterized by a sufficiently compact andlightweight structure to enable a user to easily grasp, maneuver andoperate the device using one or both hands. A handheld display device401 may generally be smaller and lighter than the primary display device121 (e.g., monitor), and may in certain embodiments be referred to as asecondary display device. In some embodiments, display device 401 may bea mirror of display device 121 and may display all or a portion of thesame information as is shown on display device 121. Alternately, displaydevice 401 may display different information than is shown on displaydevice 121. In some embodiments, display device 121 may be omitted, andhandheld display device 401 may be the only display device operablyconnected to the image-guided surgery system 400. In such a case,display device 401 may be referred to as the primary display device.Further, although a single handheld display device 401 (i.e., a tabletcomputer) is shown in FIG. 4, it will be understood that multiplehandheld display devices 401 may be simultaneously connected to and usedwith the system 400.

The handheld display device 401 may be coupled to the image-guidedsurgery system 400 by a wired or wireless communication link. In oneembodiment, the handheld display device 401 may communicate with thesystem 400 over a wireless communication interface. The system 400 maystream digital video data (e.g., high-definition video) for display onthe handheld display device 401, such as over a wireless local areanetwork (WLAN) connection, including a IEEE 801.11 (e.g., WiFi)connection. The system 400 may also exchange other signals with thehandheld display device 401 (e.g., control signals from the system 400and/or user commands received at a user interface, such as atouchscreen, on the display device 401) over a wireless connection. Thesystem 400 and the display device 401 may communicate over any suitablewireless protocol or standard, such as over a IEEE 802.15x (e.g., aBLUETOOTH®) connection.

An image-guided surgical system 400 according to various embodiments mayprovide a plurality of modes for displaying patient information. Forexample, a first display mode may include displaying a 3D image dataset(e.g., an x-ray CT, MRI, sonogram, PET or SPECT image dataset) inmultiple two-dimensional slices corresponding to anatomic planes (e.g.,axial, sagittal, coronal planes) transecting the patient. This isillustrated in the screenshot of a display device shown in FIG. 5. Thedisplay device may be a display device 121 (e.g., monitor) or a handhelddisplay device 401 as shown in FIG. 4. The display screen 500 in thisexample illustrates four different patient images in four quadrants ofthe display screen 500. Three of the quadrants (i.e., top left, topright and bottom left quadrants of display screen 500) depict differenttwo-dimensional slices 501, 503, 505 of CT image data. A fourth quadrant(i.e., lower left quadrant of display screen 500) includes a 3D volumerendering 507 illustrating a “virtual” view of anatomic feature(s)(e.g., bony structures or other discrete internal anatomic features).The two-dimensional slices 501, 503, 505 correspond, respectively, toviews taken along axial, sagittal and coronal planes through the patient200. This is illustrated schematically in FIG. 6A, which illustrates aportion of the patient 200 lying flat on a support surface 60 (i.e.,along the patient or z-axis in FIG. 6A). The axial slice 501 depicts across-section through the patient 200 in the x-y plane 601 (i.e.,transverse to the patient or z-axis). Any arbitrary axial slice 501through the patient 200 may be shown on the display screen 500. In oneembodiment, the display screen 500 may display a default axial slice 501which may correspond to the slice passing through the center of thereconstructed volume. The sagittal slice 503 depicts a cross-sectionthrough the patient 200 in the y-z plane 603 (i.e., separating the rightand left sides of the patient 200), as shown in FIG. 6A. Any arbitrarysagittal slice 503 within the reconstructed volume may be shown on thedisplay screen 500. In one embodiment, the display screen 500 maydisplay a default sagittal slice 503 which may correspond to amid-sagittal slice (i.e., passing through the midline of the patient) ora slice through the center of the reconstructed volume. The coronalslice 505 depicts a cross-section through the patient 200 in the x-zplane 605 (i.e., parallel to the patient table 60 and separating thefront and back sides of the patient 200), as shown in FIG. 6A. Anyarbitrary coronal slice 505 within the reconstructed volume may be shownon the display screen 500. In one embodiment, the display screen 500 maydisplay a default coronal slice 505 which may correspond to amid-coronal slice (i.e., transecting the anterior and posterior halvesof the patient 200) or a slice through the center of the reconstructedvolume. In some embodiments, the default coronal slice 505 that isdisplayed may be based on a particular anatomic feature in the imagedata (e.g., through a portion of the patient's spine for spine surgery)or in a plane at a particular height in the y-axis direction (e.g., at aparticular distance from the patient table 60 and/or a depth from thetop of the patient).

The display screen 500 may also display graphical elements illustratingthe relationship of each slice 501, 503, 505 relative to the otherslices shown on the display screen 500. For example, as shown in FIG. 5,the axial slice 501 image data may include an overlay of a cross pattern515 showing the intersection of the axial slice 501 with the planescorresponding to the sagittal and coronal slices 503 and 505 shown onthe display screen 500. Similar cross patterns 515 may be displayedoverlaying the display of image data in the sagittal and coronal slices503 and 505. The display screen 500 may also include graphicalrepresentations or renderings of other objects or tools tracked by themotion tracking system 105. In the example of FIG. 5, a graphicalrepresentation of a tool 509 is shown in the lower right quadrant of thedisplay screen 500. The graphical representation of the tool 509 mayillustrate the position and orientation of the tool relative to theanatomic features depicted in the 3D volume rendering 507. Similargraphical elements may be displayed in the 2D slice images 501, 503 and505 to illustrate the position and/or orientation of one or more objectswith respect to the patient.

It will be understood that the four-quadrant view shown in FIG. 5 is onepossible implementation of a display of patient information on a displaydevice 121, 401. Other possible display modes are possible. For example,rather than illustrating multiple different images (e.g., slices) from apatient image dataset (e.g., reconstructed volume), the display screen500 may show only a single image (e.g., a single axial, sagittal orcoronal slice 501, 503, 505 or a single 3D volume rendering 507). Thedisplay screen 500 may illustrate only two slices corresponding todifferent anatomic planes (e.g., axial and sagittal, axial and coronal,or sagittal and coronal slices), or may illustrate a single slice alongwith a 3D volume rendering. In some embodiments, the display screen 500may illustrate multiple two-dimensional slices corresponding to the sameanatomic planes (e.g., multiple axial, sagittal and/or coronal slicestaken through different sections of the reconstructed volume) and/ormultiple 3D volume renderings viewed from different angles. Thedifferent images and display modes of the display screen 500 may becustomizable based on user selections, which may be made via a userinput device and/or user voice commands. In embodiments, the user may beable to select (e.g., scroll through) different patient images, such assequentially illustrating multiple axial, sagittal and/or coronal slicestaken through different sections of the reconstructed volume, orsequentially illustrating multiple 3D volume renderings viewed fromdifferent angles. The user may also have the capability to control themagnification of images, such as by zooming into or out from aparticular portion of an image shown in the display screen 500. The usermay control the selection of patient images for display using a userinput device, voice commands and/or via a separate tool, such as apointer device.

In various embodiments, at least a portion of the image data displayedon the display device 121, 401 may be modified in response to a changein at least one of the position and orientation of the robotic arm 101with respect to the patient 200. This is schematically illustrated inFIG. 6B, which illustrates an end effector 102 of a robotic arm 101positioned over a patient 200. The end effector 102 may have a markerdevice 202 that enables the end effector 102 to be tracked by theoptical sensing device 111 of the motion tracking system 105, asdescribed above. Another marker device 115 may be fixed to the patient200 so that the position and/or orientation of the end effector 102 maybe tracked relative to the patient coordinate system. The motiontracking system 105 may determine the location of a portion of the endeffector 102, such as a tip end 607 of the end effector (e.g., a tip ofa cannula 609 or other tool holder), which may have a known fixedgeometric relationship to the marker device 202, within the patientcoordinate system. The display screen 500 of the display device 121, 401may display different portions of the patient image dataset (e.g., athree-dimensional tomographic reconstruction) based on the detectedposition of the tip end 607 of the end effector 102.

In the embodiment of FIG. 6B, for example, the display screen 500 maydepict the two-dimensional axial slice 611 of the image dataset thatcorresponds to the axial position of the tip end 607 of the end effector102 with respect to the patient 200 (e.g., the position of the tip end607 along the length of the patient 200 in the z-axis direction). As therobotic arm 101 moves with respect to the patient 200, the displayscreen 500 may be updated to show the axial slice(s) 611 correspondingto the current position of the tip end 607 of the end effector 102 withrespect to the patient 200.

Similarly, the display screen 500 may depict the two-dimensionalsagittal slice 613 of the image dataset that corresponds to the sagittalposition of the tip end 607 of the end effector 102 with respect to thepatient 200 (e.g., the position of the tip end 607 along the width ofthe patient 200 in the x-axis direction). As the robotic arm 101 moveswith respect to the patient 200, the display screen 500 may be updatedto show the sagittal slice(s) 613 corresponding to the current positionof the tip end 607 of the end effector 102 with respect to the patient200.

The display screen 500 may also depict a two-dimensional coronal slice615 based on the position of the tip end 607 of the end effector 102with respect to the patient 200. In one embodiment, the display screen500 may depict a coronal slice 615 of the image dataset that is offsetfrom the position of the tip end 607 (i.e., in the y-axis direction) bya pre-determined distance, d. The off-set distance, d, may be auser-adjustable parameter. As the robotic arm 101 moves with respect tothe patient 200, the display screen 500 may be updated to show thecoronal slice(s) corresponding to the position of the tip end 607 offsetby the pre-determined distance, d.

In further embodiments, the display screen 500 may display obliquetwo-dimensional slices of the patient image dataset (e.g., athree-dimensional tomographic reconstruction) based on the detectedposition and orientation of the tip end 607 of the end effector 102.This is schematically illustrated by FIG. 6C. The tip end 607 of the endeffector 102 may have up to six degrees of freedom with respect to thepatient 200—i.e., displacement along the x, y and z axes as well aspitch, yaw and roll rotation about these axes. The motion trackingsystem 105 may determine both the position (i.e., displacement) andorientation (i.e., rotation) of the tip end 607 of the end effector 102with respect to the patient coordinate system. In embodiments, thedisplay screen 500 may display two-dimensional slices through thepatient image dataset with reference to both the position andorientation of the tip end 607 of the end effector 102. In embodiments,the display screen 500 may display axial, sagittal and coronal slicesthrough the image dataset based on the position of the tip end 607 ofthe end effector 102 as described above with reference to FIG. 6B, whereeach of the slices may be rotated relative to the anatomic planes of thepatient 200 based on the orientation of the tip end 607 of the endeffector 102.

This is schematically illustrated by FIG. 6C, which shows an endeffector 102 positioned over and rotated with respect to the patient200. In this embodiment, the trajectory defined by the cannula 609 ofthe end effector 102 is rotated to an oblique angle with respect to thepatient 200 in one or more rotational degrees of freedom. In thisexample, the oblique “coronal” slice through the patient 200 maycorrespond to a plane 619 that is normal to a ray 617 projected forwardfrom the tip end 607 of the end effector 102 along the trajectorydefined by the cannula 609 and that is off-set from the tip end 607 by apre-determined distance, d. As in the embodiment of FIG. 6B, the off-setdistance, d, may be a user-adjustable parameter. The ray 617 may furtherdefine the intersection of the planes 621 and 623 of the oblique “axial”and “sagittal” slices, respectively, which may be orthogonal to eachother and to the plane 619 of the oblique “coronal” slice. Put anotherway, the tip end 607 of the end effector 102 may define an end effectorcoordinate system having a first axis (e.g., a y′ axis) extendingtowards the patient along the direction of the ray 617, andmutually-perpendicular second and third axes (e.g., z′ and x′ axes)extending from the tip end 607 in a plane normal to the first axis,where the planes 621, 629 and 619 of the oblique “axial,” “sagittal” and“coronal” slices may be based on the position and rotation of the endeffector coordinate system with respect to the patient coordinatesystem. The oblique “axial”, “sagittal” and/or “coronal” slicescorresponding to planes 621, 629 and 619, respectively, may be shown onthe display screen 500.

As the robotic arm 101 moves with respect to the patient 200, thedisplay screen 500 may be updated to show the oblique axial, sagittaland/or coronal slices based on the current position and orientation ofthe end effector 102 with respect to the patient 200.

In various embodiments, the intersection of the three image planes(i.e., axial, sagittal and coronal) may coincide with a target positionwithin the patient's body. The surgeon may use the display panel 500 asa “virtual cutting tool” to move through the various slices/views of thepatient image volume and to identify and select a target region for asurgical intervention. In embodiments, the surgeon may move through thevarious views of the patient image volume by moving the robotic arm 101with respect to the patient 200, as discussed above with reference toFIGS. 6B and 6C. The display panel 500 may also enable the surgeon tovisualize multiple trajectories or paths extending from the patient'sskin surface through the patient's anatomy to the target position. Inthe embodiment of FIG. 6C, for example, the surgeon may view a set oftrajectories in multiple planes by moving the tip end 607 of endeffector 102 of the robotic arm 101 over a virtual spherical surfacecentered on a particular target point within the patient 200. Asdiscussed above, a ray 617 projected forward from the tip end 607 of theend effector 102 may define the intersection between multiple imageslices shown on the display screen 500, and may further define a uniquetrajectory through the patient 200. The pre-determined displacementdistance, d, from the tip end 607 of the end effector 102 may define thetarget position along the unique trajectory.

The user (e.g., a surgeon) may be able to set one or more targetpositions and/or trajectories within the patient 200. There may be avariety of ways to set a target position or a target trajectory. Forexample, the surgeon may move through different views of the patientimage data by moving a robotic arm 101 as discussed above or by usinganother tool (e.g., a pointer device). Alternately, the surgeon maydirectly manipulate and interact with the displayed image data toidentify a particular target or trajectory, such as using a workstationcomputer. A particular target point or trajectory may be set by thesystem 400 in response to an input event, which may include, forexample, a voice command, a touch event on a touchscreen interface,and/or an input on a user interface device (e.g., a keyboard entry, amouse click, a button push, etc.). In embodiments, the surgeon may set atarget position and/or trajectory by interacting with image datadisplayed on a display device, such as display devices 121 and/or 401.For example, the surgeon may define a target point and/or trajectory inthe patient 200 by selecting one or more points on a display screen 500of a display device 121, 401 (e.g., marking the points using a stylus, acursor or mouse pointer, or a touch on a touchscreen user interface). Todefine a trajectory, for instance, the user may select two or morepoints in the image data (e.g., a target point and an entrance point onthe skin of the patient). In embodiments, the user may be able to makefine adjustments to a selected target point and/or trajectory using anysuitable user interface device. Multiple target points and/ortrajectories may be set and saved in a memory (e.g., in an image-guidedsurgery system 400 as illustrated in FIG. 4), where each target pointand/or trajectory may be saved in association with a unique identifier(e.g., file name).

In embodiments, the display screen 500 may display graphical element(s)overlaying the image data corresponding to one or more target positionsand/or trajectories that are set by the user. For example, definedtarget positions may be illustrated as identifiable dots or points inthe image data, which may be color coded and/or labeled on the displayscreen 500 to enable easy visualization. Alternately or in addition,defined trajectories may be depicted as identifiable lines or linesegments in the image data, which may be similarly color coded and/orlabeled. As discussed above, the display screen 500 may also displaygraphical elements associated with particular tools or objects,including invasive surgical tools or instruments, that are tracked bythe motion tracking system 105. In embodiments, the display screen 500may depict at least a portion (e.g., a tip end) of a surgical instrumentas it is inserted into the patient 200, which may enable the surgeon totrack the progress of the instrument as it progresses along a definedtrajectory and/or towards a defined target position in the patient 200.

In various embodiments of a robotically-assisted surgical system, arobotic arm 101 may be operated in a number of different operatingmodes. For example, the robotic arm 101 may operate in a hand guidingmode in which the movement of the robotic arm 101 may be controlledbased on a force applied by a user to the arm (e.g., using torque and/orforce sensing feedback to a robotic control system 405 as shown in FIG.4). The robotic arm 101 may also operate in an autonomous mode in whichthe robotic arm 101 moves to particular poses in response to controlsignals from the robotic control system 405 (e.g., in accordance with arobotic motion planning algorithm and/or in response to signals from aseparate user controller device, such as a joystick controller). Therobotic arm 101 may also operate in a static or braked mode in which therobotic arm 101 may hold a particular pose and does not move. In someembodiments, the robotic arm 101 may also operate in various additionalmodes that may be combinations of the modes described above. Forexample, the robotic arm 101 may operate in a hybrid mode in which therobotic arm 101 (or a portion thereof) may be moved by hand guiding forcertain movements of the arm (e.g., along certain directions ororientations) but may be rigid (e.g., braked) and/or provide increasedresistance to other movements of the arm.

The various operating modes of the robotic arm 101 may aid in theperformance of a surgical procedure, such as a minimally-invasive spinalsurgical procedure or various other types of orthopedic, neurological,cardiothoracic and general surgical procedures. For example, the surgeonmay move the robotic arm 101 in hand guiding mode over the patient 200to cause the display screen 500 to display various views or slices ofthe patient image volume, as discussed above with reference to FIGS. 6Band 6C. Based on the image data displayed on the display screen 500, theuser may set a particular target position and/or trajectory using avoice command or another input event as described above. In someembodiments, in response to the user setting a target position ortrajectory, the robotic arm 101 may be configured to hold its currentpose with the tip end 607 of the end effector 102 pointing along thepre-determined trajectory to the target position within the patient'sbody. Alternately, the target position and/or trajectory may be definedusing another method (e.g., using a pointer device or via userinteraction with a display device 121, 401) and/or the targetposition/trajectory may be previously set and stored in a memory. Inresponse to a user command for the robotic arm 101 to go to the targetposition or trajectory, the robotic arm 101 may be configured toautonomously move to a pose with the tip end 607 of the end effectorpointing along the pre-determined trajectory to the target position.

In some embodiments, when the robotic arm 101 is pointed along a settrajectory to a target position, the robotic arm 101 may maintain arigid or fixed pose to enable the surgeon to insert an instrument ortool through the cannula 609 into the body of the patient 200 along theset trajectory. Alternately or in addition, the robotic arm 101 mayoperate in a hybrid or compliant mode such that the robotic arm 101 maybe hand guided in a limited range of motion (e.g., along the settrajectory towards or away from the patient 200) while all other motionsmay be braked. In some embodiments, the robotic arm 101 may be handguided with increased resistance and/or reduced velocity around theinitial set trajectory to enable the surgeon to make fine adjustments tothe position and/or orientation of the trajectory. In other embodiments,the robotic arm 101 may enable a degree of compliance or movement withrespect the set trajectory in response to an applied force on the arm,but may be configured to “snap back” to the initial set trajectory whenthe applied force is released. In further embodiments, surgeon may set atarget position within the patient without specifying a particulartrajectory for reaching the target, and the robotic arm 101 may enablehand guiding over a limited range of motion such that the tip end 607 ofthe end effector 102 is always pointed along a trajectory thatintersects with the set target position in the patient's body. In thisway, the surgeon may be able to identify an optimal pathway through thepatient to reach the target position. In still further embodiments, therobotic arm 101 may enable hand guiding of at least a portion of therobotic arm over at least a limited range of motion while the roboticcontrol system 405 may control the robotic arm 101 to make compensatingmovements (e.g., based on the inverse kinematics of the robotic arm 101)to maintain the tip end 607 of the end effector 102 along the settrajectory relative to the patient. For example, this may enable thesurgeon to move a portion of the robotic arm 101 out of his or her waywhile maintaining the end effector 102 in a fixed position and/ororientation relative to the patient 200.

The target positions and/or trajectories within the patient 200 may bedefined in the common coordinate system, which as noted above, may befixed with respect to the marker device 115 (i.e., patient referencearc) that is rigidly secured to a nearby anatomic feature (e.g., a bonystructure). The motion tracking system 105 may detect any movement ofthe patient 200 and the robotic control system 405 may control therobotic arm 101 to compensate for any detected patient movement andmaintain the tip end 607 of the end effector 102 pointed along the settrajectory in the common coordinate system. Further, when the roboticarm 101 is instructed to move to or return to a particular trajectorywhich may have been previously set while the patient 200 is in aninitial position, the robotic arm 101 may move or return to that sametrajectory with respect to surgically relevant portion of the patient'sanatomy, even if the patient 200 has been subsequently moved from theinitial position.

In further embodiments, at least a portion of the image data displayedon the display device 121 and/or 401 may be modified in response to achange in at least one of the position and orientation of a displaydevice 401 with respect to the patient 200. In embodiments, the motiontracking system 105 may track the position and/or orientation of adisplay device. The display device 401 may be a handheld display deviceas described above. The handheld display device 401 may have one or moremarker devices 701 fixed thereto, as schematically illustrated in FIG.7A, which may enable the motion tracking system 105 to track theposition and/or orientation of the handheld display device 401 when itis within range of the motion tracking system 105 (e.g., within thefield of view of an optical sensing device 111, as shown in FIG. 7B).The one or more marker devices 701 may be in a known fixed geometricrelationship with a particular point, P, on the handheld display device401. The particular point, P, may define a coordinate system of thehandheld display device 401. The point, P, may be at any arbitrarylocation on the handheld display device 401, such as at the center ofthe device 401, along an edge or midline of the device 401, or at acorner of the device 401. In embodiments, the coordinate system of thehandheld display device 401 may include two mutually perpendicular axes(e.g., z′ and x′ axes) that extend parallel to the length and widthdimensions of the device 401 and a third axis (e.g., y′ axis) thatextends normal to a major surface of the device 401.

In embodiments, the motion tracking system 105 may determine thelocation of at least a portion the handheld display device 401, such asthe location of a particular point, P, on the device 401, within thepatient coordinate system. The display screen 500 of the display device401 may display different portions of the patient image dataset (e.g., athree-dimensional tomographic reconstruction) based on the detectedposition of the at least a portion of the handheld display device 401.In embodiments, the display screen 500 may begin displaying patient databased on the detected position of the handheld display device 401 whenthe device 401 is moved into a particular area, such as over the patient200 or within a predetermined proximity to the patient surgical site. Inembodiments, the display screen 500 may display patient data based onthe detected position of the handheld display device 401 whenever thedevice 401 is within range (e.g., within the field of view) of themotion tracking system 105. In embodiments, the detected position and/ororientation of the handheld display device 401 may also determine, atleast in part, the patient images shown on one or more additionaldisplay devices, such as a stationary monitor 121 as shown in FIG. 1.The one or more additional display devices 121 may mirror the display ofpatient images shown on the handheld display device 401.

In the embodiment of FIG. 7B, the display screen 500 may depict atwo-dimensional axial slice 711 of the image dataset that corresponds tothe axial position of a portion the handheld display device 401 (e.g.,point P) with respect to the patient 200. As the handheld display device401 is moved with respect to the patient 200 (e.g., up and down thelength of the patient in the z-axis direction), the display screen 500may be updated to show the axial slice(s) 711 corresponding to thecurrent position of the handheld display device 401 with respect to thepatient 200.

The display screen 500 may also depict a two-dimensional sagittal slice713 of the image dataset that corresponds to the sagittal position of aportion the handheld display device 401 (e.g., point P) with respect tothe patient 200. As the handheld display device 401 is moved withrespect to the patient 200 (e.g., side-to-side along the width of thepatient in the x-axis direction), the display screen 500 may be updatedto show the sagittal slice(s) 713 corresponding to the current positionof the handheld display device 401 with respect to the patient 200.

The display screen 500 may also depict a two-dimensional coronal slice715 of the image dataset based on the position of a portion the handhelddisplay device 401 (e.g., point P) with respect to the patient 200. Inone embodiment, the display screen 500 may depict a coronal slice 715 ofthe image dataset that is offset from the position of the portion of thehandheld display device 401 (i.e., point P) by a pre-determineddistance, d. The off-set distance, d, may be a user-adjustableparameter. As the handheld display device 401 is moved with respect tothe patient 200 (e.g., towards or away from the patient along the y-axisdirection), the display screen 500 may be updated to show the coronalslice(s) corresponding to the current position of the handheld displaydevice 401 offset by the pre-determined distance, d.

The display screen 500 may also depict a three-dimensional volumerendering illustrating a “virtual” view of anatomic feature(s) (e.g.,bony structures or other discrete internal anatomic features) as viewedfrom the current position and/or orientation of the handheld displaydevice 401 (i.e., point P), where the “virtual” view may be updatedbased on the movement of the handheld display device 401.

In further embodiments, the display screen 500 may display obliquetwo-dimensional slices of the patient image dataset (e.g., athree-dimensional tomographic reconstruction) based on the detectedposition and orientation of the handheld display device 401. This isschematically illustrated by FIG. 7C. In various embodiments, thedisplay screen 500 may display two-dimensional slices (e.g., axial,sagittal and/or coronal slices) through the patient image dataset basedon the position and orientation of the display 401 coordinate systemwith respect to the patient coordinate system. In other words, theoblique “axial” slice may be a cross-section of the patient imagedataset taken in the x′-y′ plane 717 of the display 401 coordinatesystem, the oblique “sagittal” slice may be a cross-section of thepatient image dataset taken in the y′-z′ plane 719 of the display 401coordinate system, and the oblique “coronal” slice may be across-section of the patient image dataset in a plane that is parallelto the x′-z′ plane 721 of the display 401 coordinate system and offsetalong the y′-axis direction by the pre-determined offset distance, d.

In various embodiments, the user (e.g., surgeon) may move the handhelddisplay device 401 over and around the patient surgical site to providea “virtual window” into the patient's anatomy. The user may manuallyhold and move the handheld display device 401 over the patient 200and/or the handheld display device 401 may be mounted to a movable armthat may be positioned over the patient 200. The movable arm may bemanually moveable and/or may be a robotic arm. In embodiments, theintersection of the three image planes (i.e., axial, sagittal andcoronal) shown on the display panel 500 of the handheld display device401 may coincide with a target position within the patient's body. Thus,the user may use the handheld display device 401 as a “virtual cuttingtool” to move through the various slices/views of the patient imagevolume and to identify and select a target region for a surgicalintervention. The user may manipulate the handheld display device 401 todisplay multiple trajectories or paths extending from the patient's skinsurface through the patient's anatomy to the target position. The usermay define one or more trajectories as discussed above via a direct userinteraction with the display device 401 (e.g., via a touchscreen orstylus entry on the device 401) and/or via voice command or any of thetechniques discussed above.

A handheld display device 401 (e.g., a tablet, smartphone, etc.) mayinclude a camera (e.g., a digital camera) for obtaining photographsand/or video images. The camera may be rear-facing (i.e., on theopposite side of the device 401 from the display screen 500). Thedisplay device 401 may enable images obtained from the camera, includingreal-time video images, to be shown on the display screen 500 of thedevice. In some embodiments, the display screen 500 may display at leasta portion of the patient image dataset (e.g., a three-dimensionaltomographic reconstruction of a patient's anatomy) overlaying areal-time video image of the patient. In various embodiments, thedisplay screen 500 may display different portions of the patient imagedataset based on the camera's location with respect to the body of thepatient.

FIGS. 7D-7E illustrate a handheld display device 401 having arear-facing camera (schematically illustrated by 732) that is configuredto images of a patient 200 obtained by the camera 732 on a displayscreen 500. In this embodiment, the display device 401 includes aplurality of markers 730 (e.g., reflective spheres) that may be attachedto the display device 401 using a suitable attachment mechanism. Themarkers 730 may enable the display device 401 to be tracked by a motiontracking system 105 as described above. In this embodiment, the markers730 are attached along a first edge of the display device 401 so thatuser (not shown) may securely grasp and hold the display device 401 byor between the other edges without occluding the markers 730 from thefield of view of the optical sensor device 111 of the motion trackingsystem 105.

The motion tracking system 105 may track the position and orientation ofthe handheld display device 401. One or more additional markers 731 onthe patient 200 may enable the position and orientation of the displaydevice 401 to be determined relative to the patient 200. The patientmarker(s) 731 may further enable registration of patient images (e.g.,CT and/or MRI data) in a common coordinate system, as discussed above.In embodiments, the images from the camera 732 (e.g., real-time videoimages) may be overlaid with a three-dimensional volume renderingillustrating a “virtual” view of anatomic feature(s) (e.g., bonystructures or other discrete internal anatomic features) as viewed fromthe current position and/or orientation of the handheld display device401. A calibration process, which may be performed by a processor on thedisplay device 401 and/or on another device (e.g., computer 113 shown inFIG. 1), may be used to match the three-dimensional volume rendering tothe field of view of the camera 732 so that the images of the patient200 taken by the camera may be augmented by a rendering of theunderlying anatomical features as viewed from the same camera position.

This is illustrated in FIG. 7D, which shows the handheld display device401 positioned such that a portion of the patient 200 is within thefield of view of the camera 732. The display screen 500 shows a videoimage of the patient 200 that is overlaid by a three-dimensional volumerendering 734 of the corresponding internal anatomy (shown in phantom).The volume rendering may be updated as the handheld display device 401is moved with respect to the patient 200 so as to depict thecorresponding internal anatomy as viewed from the updated cameraposition. This is illustrated in FIG. 7E, which shows the updatedthree-dimensional volume rendering 735 as the handheld display device401 is moved along the length of the patient 200. In embodiments, theaugmented images shown on the display screen 500 of the handheld displaydevice 401 may be mirrored on one or more additional display screens,such as a monitor display 121 as shown in FIG. 1.

In some embodiments, the user may be able to make the superimposed imagedata (e.g., 3D volume rendering 734) more or less transparent relativeto the camera images (e.g., real-time video images) shown on the displayscreen 500. A slider 735 or similar graphical interface element on thedisplay screen 500 (e.g., a touchscreen display) may be used to adjustthe relative transparency of the 3D volume rendering relative to thecamera images, as shown in FIG. 7F.

A handheld display device 401 such as shown in FIGS. 7D-7F may be usedbefore, during and/or after a surgical procedure to provide the surgeonwith a “virtual” window into the patient's anatomy, as described above.Alternately or in addition, a handheld device 401 such as shown in FIGS.7D-7F may be used for diagnostic purposes by providing a dynamic toolfor looking around the patient and into the underlying anatomy. Thehandheld device 401 may be used as an explanatory aid for patients. Insome embodiments, the patient marker 731 may be fixed over the skinsurface of the patient 200 (e.g., via an adhesive or other means) andmay include an x-ray opaque beebee or other element identifiable in theimage data to enable registration of the image data to the coordinatesystem of the motion tracking system 105.

A handheld display device 401 as described above may be located withinor moved into the surgical sterile field. Since typical handheldelectronic devices, such as tablet computers, are not sterile orsterilizable, the handheld display device 401 may be placed within asterilized enclosure, such as a sterile drape or bag. However, a typicalsterile bag or covering used in a surgical environment may negativelyimpact the functionality of a handheld computing device, such as byobscuring the view of the display screen, interfering with user inputcomponents, such as a touchscreen user interface, and/or interferingwith the motion tracking of the device. A sterile bag or covering mayalso make the device more difficult to hold and manipulate by a user.

FIGS. 8A-8E illustrate a sterile case 800 for a handheld display device401 according to an embodiment. FIG. 8A is a front elevation view of thecase 800 and FIG. 8B is a rear elevation view of the case 800. As shownin the perspective view of FIG. 8C, the case 800 may have a clamshelldesign, with a first portion 801 connected to a second portion 803 by ahinge portion 805. The first portion 801 and the second portion 803 maybe folded over on the hinge portion 805 to enclose a handheld displaydevice 401 between the first and second portions 801, 803. When thefirst portion 801 and the second portion 803 are folded together, theinterfacing surfaces of the first and second portions 801, 803 maydefine an interior housing 807 of the case 800. In embodiments, theinterior housing 807 may be dimensioned to correspond to the dimensionsof a handheld display device 401 received therein. An outer surface ofthe first portion 801 may define the front surface 802 of the case 800and an outer surface of the second portion 803 may define the rearsurface 804 of the case 800.

The case 800 may be made from a sterile, transparent material, such as aplastic, and may be relatively low-cost. In embodiments, the case 800may be a single-use disposable component. In other embodiments, the case800 may be re-sterilizable (e.g., autoclavable), and may be a reusablecomponent. In embodiments, the case may be custom designed for use witha particular handheld display device (e.g., tablet computer, pendantcontroller, etc.).

In various embodiments, the case 800 may have an integrated markerdevice to enable the case 800 and handheld display device 401 to betracked by a motion tracking system, as described above. In oneembodiment, a plurality of markers 809 (e.g., IR reflective spheres) maybe mounted to the case 800. In embodiments, the markers 809 may beenclosed within the case 800 and may form an array pattern that may betracked by a motion tracking system. Alternately or in addition, aseparate marker array pattern may be attached to the outside of the case800. As shown in FIG. 8C, the case 800 may have a plurality of internalpockets 811 that may be sized and shaped to receive spherical reflectivemarkers 809. The pockets 811 may be disposed around an outer peripheryof the case 800, and may have an asymmetric pattern such that the markerarray may have a different geometry when viewed from the front 802 andback 804 of the case 800. Instead of reflective spheres, the markers 809can also be flat (e.g., disk-shaped) reflective markers that may belocated within the case 800 or attached to an outer surface of the case800.

The case 800 may have a sufficiently rigid construction to prevent themarkers 809 from moving relative to one another and relative to thehandheld display device 401. The front surface 802 of the case mayinclude a substantially flat window region 812 that encompasses thedisplay screen of the handheld display device 401. The window region 812may be sufficiently rigid to inhibit distortion when viewing displayscreen through the window region 812, and may relatively thin to enabletouchscreen control of the display device through the case 800. In someembodiments, the window region 812 may have an anti-glare and/oranti-reflective coating to minimize the impact of external reflections,such as from overhead surgical lights. In some embodiments, when thecase 800 and display device 401 are determined to be in proximity to thepatient surgical site by the motion tracking system 105, a signal may besent to a controller for controlling a light source (e.g., overheadsurgical lights) to cause the light source to modify the room lighting(e.g., dimming or changing the focus of the lights) to enable thedisplay to be more clearly viewed.

The first and second portions 801, 803 of the case 800 may have matingportions 813 (e.g., projections, detents, etc.) that may fit together tohold the case 800 in a closed position. The case 800 may also include anadditional locking mechanism 815 that may be secured over the case 800to hold the case 800 in a closed position. As shown in FIGS. 8D and 8E,the locking mechanism 815 may include a slider 816 that may be insertedover and slid along a track 818 on the periphery of the case 800 toensure that the case 800 does not accidentally open during a surgicalprocedure. In some embodiments, the locking mechanism 815 may alsoenable the case 800 to be mounted to a separate support element. Forexample, as shown in FIGS. 8D and 8E, the upper portion of the slider816 may include a projection 819 that may function as a latch portion(e.g., a strike plate) when the projection 819 is inserted into areleasable latching member 821 on the support element. The releasablelatching member 821 may function similarly to a seatbelt belt buckle ina vehicle. The support element may include one or more features 823 thatmay mate with corresponding features 826 (see FIG. 8B) on the rearsurface 804 of the case 800. For example, the support element mayinclude a loop member 823 that may fit within an arc-shaped detent 826formed in the rear surface 804 of the case 800. Other mechanisms formounting the case 800 to a support may be utilized. The case 800containing the handheld display device 400 may be easily removable fromthe support element by a user, and may be easily re-attached to thesupport element. In embodiments, the rear surface 804 of the case 800may have handles 827, which may be molded features in the rear surface804, to facilitate easy grasping and manipulation of the case 800 anddisplay device 401 by the user.

FIG. 8F illustrates a handheld display 401 within a sterile case 800that is mounted to an adjustable support 850 (e.g., a gooseneck,balanced-arm or pivoting-arm support stand). The support 850 for thehandheld display device 401 may be attached to the patient table 60,such as by mounting the support 901 to surgical side rails. The support850 may be attached to any other component, such as a separate cart, theimaging device 103, a robotic arm 101, or may be suspended from anoverhead structure (e.g., overhead lights). In one embodiment, one ormore handheld display devices 401 may be suspended from an arm 209extending above the patient 200 surgical area, which may also support anoptical sensor device 111 for the motion tracking system.

In some embodiments, at least one display device 900 may be provided ona robotic arm 101, as is illustrated in FIG. 9. The at least one displaydevice 900 may optionally display status and system information relatedto the operation of robotic arm 101 and may also be used for displayingpatient information, including imaging data obtained using an imagingdevice 103, as well as surgical navigation data from an image-guidedsurgery system 400. The image data may include 2D slices of athree-dimensional image dataset (e.g., a tomographic reconstruction)and/or a 3D volume rendering of all or a portion of the image dataset.The images displayed on display device 900 may include all or a portionof the images that may be displayed on display devices 119 and/or 401,as described above. Thus, the at least one display device 900 on therobotic arm 101 may be a mirror of display device 119 and/or 401. Theimages may be reformatted to fit within the display device 900. In otherembodiments, the images displayed on display device 900 may be differentfrom those shown on a separate stationary display (e.g., monitor 119) ora handheld display device 401. In embodiments, multiple display devices900 may be provided on different sections of a robotic arm 101. Eachdisplay device may display the same or different images (e.g., eachdisplay 900 may display a different 2D slice of a three-dimensionalimage dataset). The display(s) 900 may further include user interfacecomponents (e.g., touchscreen interface, buttons, etc.) that may enablea user to control what is shown on the display device 900 and/or controla function or operation of the robotic arm 101.

The robotic arm 101 may be an articulated robot having a plurality ofrotary joints 901 with linkage members 903 between the joints 901. Inmany cases, the linkage members 903 may have a generally curvilinear orcylindrical shape around their outer periphery (i.e., circumference). Inembodiments, the at least one display device 900 may be located on oneor more linkage members 903 of the robotic arm 101. In some embodiments,a display device 900 may include a contoured viewing surface 905 thatmay extend around an outer periphery of the linkage member 903. Inparticular, the contoured viewing surface 905 may extend around at least50% of the outer periphery of the linkage member 903, such as between50-100% (e.g., 60-90%) of the outer periphery of the linkage member 903.

In embodiments, the display device 900 may include multiple flat-paneldisplay tiles disposed around the periphery of the linkage member 903and angled to approximate the contour of the outer surface of thelinkage member 903. Individual tiles may be controlled to display aportion of a continuous image extending over multiple tiles, with narrowmullions (e.g., <1 mm) between adjacent tiles. Each tile may have adimension that is less than 2 inches (e.g., approximately 1 inch) in thedirection extending around the periphery of the linkage member 903. Thedisplay device 900 may utilize any suitable display technology, such asan LCD display, an LED display, an OLED display or a front or rearprojection display.

In some embodiments, all or a portion of the display device 900 may beformed on a curved or flexible substrate that follows the contour of theouter surface of the linkage potion 903. The display device 900 may be,for example, an organic light-emitting diode (OLED) display on a curvedor flexible substrate. In embodiments, the display device 900 maycomprise an active matrix of organic thin-film transistors (OTFTs) on aflexible substrate coupled to a liquid crystal display (LCD) medium,such as disclosed in WO 2015/177539 by FlexEnable Ltd., which isincorporated by reference herein. In embodiments, the display device 900may comprise a reflective display having an electrophoretic displaymedium (e.g., electronic ink) on a curved or flexible substrate.

In some embodiments, one or more connections for providing power to andexchanging data with the display device 900 may be located on the outersurface of the linkage member 903. The display device 900 may be snappedover or adhered to the linkage member (e.g., using an adhesive and/ormechanical fasteners) and plugged into a connector (e.g., USB port) onthe robotic arm 101. Alternately, the display device 900 may bepermanently mounted to or integrally formed with the robotic arm 101.Wire connections to the display device 900 for power and data may extendthrough the interior of the robotic arm 101. In some embodiments, thedisplay device 900 may include transceiver circuitry to enable wirelesscommunication with a separate computer device (e.g., image guidedsurgery system 400). The display device 900 may have an internal batterypower source, and a separate power connection may not be needed.

In embodiments, a surgical drape (not shown for clarity) may be providedover the robotic arm 101 to provide a sterile barrier between therobotic arm 101 and the surgical area. The display device 900 mounted tothe robotic arm 101 may be viewable through the drape, which may be madeof a transparent material. In some embodiments, in order to improveviewability of the display device 900, the drape may be adhered to orotherwise held flat against the viewing surface of the display device900. The drape may be adhered to the viewing surface of the displaydevice 900 via an adhesive or mechanical fasteners, heat shrinking thedrape, or using suction forces. In some embodiments, the drape may beheld against the display device 900 using electroadhesion forces. Forexample, electrodes embedded in a dielectric material on the robotic arm101 and/or the display device 900 may be used to prehend the drapeagainst the viewing surface (e.g., similar to an electrostatic chuckused in semiconductor wafer processing).

In some embodiments, one or more display devices 900 may be located onthe surgical drape and may be attached to the robotic arm 101 when thedrape is placed over the robotic arm 101. The drape and the one or moredisplay devices 900 located thereon may be single-use disposablecomponents.

As noted above, linkage members 903 of the robotic arm 101 may beconnected to one or more rotational joints 901. During operation of therobotic arm, 101, each linkage member 903 and any display device(s) 900mounted thereon may thus have rotational freedom in one or moredirections. In some cases, this may interfere with the viewing of thedisplay device 900, such as where the viewing surface is rotated to adifferent orientation with respect to the viewer such that the viewingsurface is no longer visible to the viewer. In embodiments, a controlleroperatively coupled to the display device 900 may be configured todetect a rotational motion of the display device 900 with respect to aviewing position 905 and may modify at least one image shown on thedisplay device 900 in response to the detected rotational motion. Thecontroller may modify the at least one image shown on the display device900 such that it remains visible to a viewer in the viewing position 906as the portion of the robotic arm 101 on which the display device 900rotates with respect to the viewing position 906. In some embodiments,the viewing position 906 may be a location above and proximate to thesurgical area (e.g., within 5 meters, such as within 2 meters, e.g.,within 1 meter, of the surgical area), where a user (e.g., a surgeon)may view the display device 900 during a surgical procedure. The viewingposition 906 may optionally be pre-set by the user (e.g., to accommodatethe user's height and/or where the user will be situated during theprocedure, such as on a particular side of the surgical table 60), suchas by manually adjusting the display settings until the information ofinterest may be clearly viewed. The display device 900 may display theat least one image on a first portion 907 of the display device 900 suchthat the at least one image may be clearly seen from the viewingposition 905. For example, the first portion 907 may be a segment of thedisplay device around the periphery of the linkage member 903 that facesupwards towards the user. A second portion 909 of the display device 900that is not clearly viewable from the viewing position 905 (e.g., asegment of the display device 900 that faces downwards and/or away fromthe user) may not display any images.

In embodiments, the controller of the display device 900 may detect theorientation of display device 900 based on the current joint parametersof the robotic arm 101 and the known gravity vector 911 at the base 912of the arm 101 (see FIG. 8F). At least one image may be displayed basedon the detected orientation of the display device 900. For example, fora display device 900 that extends around all or substantially the entireperiphery of the linkage member 903 of the robotic arm 101, the displaydevice 900 may display at least one image on a portion of the linkagemember 903 facing opposite the gravity vector 911 (i.e., such that theimage may be seen from the viewing position 905). In embodiments, noimage may be displayed on a portion of the linkage member 903 facing inthe direction of the gravity vector 911. Alternately or in addition, theorientation of the display device 900 may be determined using aninertial measurement unit (IMU) (e.g., accelerometer(s) and/orgyroscope(s)) located on the display device 900 or the robotic arm 101,or using data from the motion tracking system 105.

In embodiments, the controller may determine a rotational motion of thedisplay device 900 relative to the viewing position 905 based on achange in the joint parameters of the robotic arm 101 and the knownkinematics of the robotic arm 101. Alternately or in addition, therotation motion of the display device 900 may be determined based on asignal from an IMU or from the motion tracking system 105. In responseto a rotational motion of the display device 900, the controller maymodify the at least one image shown on the display device 900 such thatthe one image remains visible to a viewer in the viewing position 905.For example, the at least one image may be scrolled over the surface ofthe display device 900 such that the at least one image continues toface the viewing position 905. In embodiments, the display device 900may optionally also re-orient the at least one image on the displayscreen such that the image maintains an initial orientation with respectto the viewing position 905.

In embodiments, at least one display device on a robotic arm 101 mayindicate an operational status of the robotic arm 101. For example, atleast one display device on the robotic arm 101 may provide anindication of a current operating mode of the robotic arm 101, such as ahandguided mode, an autonomous mode, a static (braked) mode or any otheroperating mode such as discussed above. The operating mode of therobotic arm 101 may be displayed on a display device 900 as describedabove, or may be displayed on a separate display device 913, which maybe an LED light pipe extending around the robotic arm 101. The operatingmode may be displayed by displaying a readily perceivable andunderstandable indicator, such as a color-coded indication of thecurrent operating mode of the robotic arm 101.

In various embodiments, a plurality of display devices 900 and/or 913may be located on multiple portions of the robotic arm 101 that aremoveable relative to one another, such as on a plurality of linkagemembers 903. In some embodiments, the robotic arm 101 may be operated ina hybrid operating mode, such that at least one portion of the roboticarm 101 may be moved by a user in a handguiding mode while anotherportion of the arm may be in a braked or increased resistance mode. Forexample, the robotic arm 101 may be in a pose such that the end effector102 of the arm 101 maintains a particular trajectory with respect to thepatient 200. In some cases, it may be desirable for a portion of therobotic arm 101 to be moved (e.g., moved out of the way of the surgeon)while maintaining the end effector 102 in the pre-determined trajectorywith respect to the patient 200. Using the known inverse kinematics ofthe robotic arm 101, the robotic control system may determine whichportion(s) of the robotic arm 101 may be safely moved while sufficientcompensating movements exist to enable the end effector 102 to maintainthe pre-determined trajectory with respect to the patient 200. Theplurality of display devices 900 and/or 913 may display differentindicators (e.g., different colors) to indicate whether a particularportion of the arm 101 may be moved in a handguiding mode. For example,a display 900, 913 on a first portion of the arm 101 (e.g., a firstlinkage member 903) may display a first color (e.g., green) to indicatethat that portion of the arm 101 may be moved via handguiding. A displayon a second portion of the arm 101 (e.g., a different linkage member)may display a second color (e.g., red) to indicate that that portion ofthe arm 101 may not be moved via handguiding. In some embodiments, thedisplay 900, 913 may display an additional indicator (e.g., a yellowcolor) to indicate that a particular portion is about to enter a brakedor locked mode, such as when the arm is moved into a configuration suchthe robotic arm 101 will no longer be able maintain the end effector 102in the pre-determined trajectory relative to the patient 200 and/or whena joint limit of the robotic arm 101 is about to be reached.

Alternately or in addition, a display 900, 913 on a portion of therobotic arm 101 may provide an indication of a direction in which theportion of the arm may be moved by handguiding. For example, as shown inFIG. 9, the display 913 on linkage member 903 may display an indicator(e.g., a first color) on a first portion 915 of the display 913 toindicate that the linkage member 903 may be moved (i.e., handguided) ina first direction (indicated by arrow 917). The display 913 may displaya second indicator (e.g., a second color), or may display no indicator,on a second portion 919 of the display 913 to indicate that the linkagemember 903 is braked in other directions. For example, the display(s)900, 913 may display a first color (e.g., green) to indicatedirection(s) in which the robotic arm 101, or a portion 903 thereof, maybe pushed in a handguiding mode. The display(s) 900, 913 may optionallydisplay a second color (e.g., red) to indicate direction(s) in which therobotic arm 101 is braked and may not be handguided. This may be used,for example, when the robotic arm 101 is in a hybrid mode such that therobotic arm 101 may be handguided over a limited range or in limiteddirection(s) (e.g., along a particular trajectory with respect to thepatient 200), but is otherwise braked.

Further embodiments include methods of performing image guided surgeryusing multiple patient reference marker devices. As discussed above, areference marker device 115 (e.g., reference arc) may be rigidlyattached to a landmark in the anatomical region of interest (e.g.,clamped or otherwise attached to a bony portion of the patient'sanatomy) to enable the anatomical region of interest to be continuallytracked by the motion tracking system 105. During an image guidedsurgical procedure, the diagnostic imaging data of the relevant anatomymay be registered to a patient coordinate system based on the positionand orientation of the reference marker device 115, which may becontinually tracked by the motion tracking system 105. In general, theaccuracy of the patient registration of the diagnostic imaging data maybe greatest at portions of the anatomy closest to the attachment pointof the reference marker device 115. The accuracy of the registration maydecrease the further one gets from the attachment point of the referencemarker device 115. This may be due to small movements of the patient'sanatomy relative to the anatomical feature to which the reference markerdevice 115 is affixed, which may cumulatively produce larger relativedisplacements the further one is from the affixation point. Thus, for acomplex surgical procedure requiring interventions over a large area ofthe patient's anatomy, such as a spinal surgery involving multiplespinal vertebral levels, a typical workflow may include performingmultiple imaging scans and patient registrations, with the patientreference marker device 115 being removed and surgically reattached todifferent portions of the patient's anatomy prior to each successivescan and registration step. This may greatly increase the duration andcomplexity of the surgical procedure.

FIG. 10A illustrates an embodiment image-guided surgical procedure usingmultiple reference marker devices 1001, 1003 fixed to a patient 200.FIG. 10A schematically illustrates a side cross-section view of thepatient's anatomy, and in particular a lower (lumbar) spinal region ofthe patient. In embodiments, a plurality of reference marker devices1001, 1003 are attached to different positions 1002, 1004 of thepatient's anatomy. Each reference marker device 1001, 1003 may berigidly attached to a different bony structure, such as a portion of avertebra (e.g., a spinous process 1006). The attachment positions 1002,1004 may be separated by a distance of 2 inches or more, such as 2-5inches, and may be separated by 4-6 inches, including about 5 inches,and in some embodiments may be separated by 6 inches or more. For aspinal surgical procedure, the attachment positions 1002, 1004 may belocated on different vertebral levels of the spine, which may beseparated by at least one, and preferably greater than one (e.g., 2-5)intervening vertebral levels. The different vertebral levels may belumbar, thoracic and/or cervical vertebral levels. The attachmentpositions 1002, 1004 may also be located on different anatomicstructures. For example, a first attachment position 1002 may be on avertebral structure and the second attachment position 1004 may be on adifferent bony structure, such as the iliac crest of the pelvis.Although two reference marker devices 1001, 1003 are shown attached tothe patient in FIG. 10A, it will be understood that more than tworeference marker devices may be attached to different portions of thepatient in various embodiments.

Each reference marker device 1001, 1003 may include an elongated memberhaving a mechanism at one end for attaching to the patient. For example,the reference marker device 1001 may include a clamp that is configuredto attach to the spinous process of a vertebra. A second end of thereference marker device 1001, 1003 may extend outside of the skin 1008of the patient 200. An array of markers (e.g., a plurality of reflectivespheres in a geometric array) may be attached to the second end of themarker device 1001, 1003 to enable the marker devices 1001, 1003 to betracked using a motion tracking system 103.

In some embodiments, the reference marker devices 1001, 1003 may beminimally-invasive reference marker devices. An example of aminimally-invasive marker device is shown in FIG. 10B. Theminimally-invasive marker device 1001 may include an elongated member(e.g., a rod) 1010 having a relatively small diameter, such as less thanabout 8 mm (e.g., 4-7 mm), including about 6 mm. The elongated member1010 may be a hollow tube. In embodiments, the elongated member 1010 maybe made from a material that may be visible in the image data, such ascarbon fiber. In the case of x-ray CT data, the elongated member 1010may function as a fiducial that is visible in the CT images and may beused by the surgeon to verify the registration accuracy, as discussedfurther below. A threaded screw 1012 may be located at one end of theelongated member 1010 for attaching to a structure in the patient'sanatomy, and an array of markers 1014 may be attached to the oppositeend. The elongated member 1010 may also include one or more additionalanchors 1016 that may dig into the surrounding bone when the screw 1012is screwed into the patient's bone to aid in affixing the marker device1001 to the patient. The threaded screw may have a maximum diameter thatis approximately equal to or less than the diameter of the rod 1010. Inembodiments, a screw driver may be inserted through the hollow interiorof the elongated member 1010 to engage with the threaded screw 1012 toaffix the marker device 1001 to a portion of the patient's anatomy.

In various embodiments of a minimally-invasive marker device, theportion of the reference marker device that is inserted into the patientmay have a smaller profile than conventional reference marker devices,which typically include clamping members for affixing to a bonystructure. In embodiments, a minimally-invasive reference marker device1001, 1003 may be inserted through a small opening or incision in thepatient's skin and the threaded screw may be screwed directly into thepatient's bone. Attaching a plurality (e.g., 2, 3, 4 or more) of suchmarker devices around the surgical area may provide redundancy such thatif one marker device is not rigidly secured or becomes loose, any lossin the accuracy of the surgical navigation may be compensated for by oneor more additional marker devices. The marker devices 1001, 1003 mayalso be used to verify the accuracy of the patient registration. Theregistration may become inaccurate, for example, if a marker device1001, 1003 becomes loose or is accidentally bumped causing it to changeits position relative to the patient during a surgical procedure. Inembodiments, the surgeon may utilize one or more marker devices 1001,1003 as a fiducial to periodically check the registration accuracyduring a surgical procedure. This may include, for example, using aninstrument (e.g., a pointer 1050 or stylus, see FIG. 10A) that istracked by the motion tracking system 105 to verify that the actuallocation of the marker device 1001, 1003 at a given time corresponds tothe location of the marker device 1001, 1003 that is visible in thepatient image(s). This may include, for example, using a pointer 1050 totouch or trace along a portion of the marker device 1001, 1003 thatprojects outside of the patient's skin and/or positioning the pointer1050 along the trajectory defined by the elongated member 1010 of themarker device 1001, 1003 to ensure that the marker device 1001, 1003 hasnot moved relative to the patient subsequent to the initialregistration. A discrepancy between the location of the marker device1001, 1003 measured using the pointer 1050 and the location of themarker device 1001, 1003 visible in the patient image(s) may indicatethat the patient registration is no longer accurate.

In embodiments, a minimally-invasive reference marker device may requirean opening through the patient's skin and muscle of less than 10 mm inwidth for insertion and fixation of the marker device to bone, comparedto conventional reference marker devices, which may require openingsthat are greater than 12 mm in width to enable the marker device to beinserted into and clamped onto the bone of the patient. In someembodiments, a minimally-invasive reference marker device may include asharp point or blade on the tip end of the device such that the markerdevice itself may be used to perform the incision through the patient'sskin. In some embodiments, the minimally-invasive marker devices may besingle-use disposable components.

FIG. 11A is a process flow diagram illustrating an embodiment method1100 for performing image-guided surgery using multiple reference markerdevices fixed to a patient. The method 1100 may be performed using animage-guided surgery system, such as system 400 described above withreference to FIG. 4. In embodiments, the multiple reference markerdevices may be reference marker devices 1001, 1003 as shown in FIG. 10Aand may be minimally-invasive reference marker devices as shown in FIG.10B. In other embodiments, the reference marker devices may beconventional (i.e., non-minimally invasive) marker devices. In block1101 of method 1100, patient images may be obtained using an imagingdevice, such as the imaging device 103 shown in FIGS. 1 and 2. Thepatent images may be a three-dimensional image dataset (e.g., a 3D CTtomographic reconstruction, a 3D MRI dataset, etc.) representing atleast a portion of the patient's anatomy, including the internal anatomyand/or structure(s) that are to be operated on (i.e., asurgically-relevant portion of the patient's anatomy). In embodiments,the three-dimensional image dataset may be obtained by performing animaging scan, such as a CT image scan. The three-dimensional imagedataset may be a representation of a volume of the patient's internalanatomy, where the anatomical volume may have at least one dimensionthat is greater than 6 inches (e.g., 6-12 inches) and preferably greaterthan about 12 inches (e.g., 12-36 inches). In embodiments, the at leastone dimension may be an axial dimension along the direction of animaging scan (e.g., an x-ray CT image scan). The three-dimensional imagedataset may be obtained by performing a scan of the patient (i.e.,moving an imaging gantry relative to the patient along the length of thepatient) while obtaining imaging data. The scan may include the anatomicfeatures to which each of the reference marker devices 1001, 1003 areattached.

In block 1103, at least a first portion of the patient images may beregistered to a first patient coordinate system that is based on a firstreference marker device 1001 fixed to a first location 1002 on thepatient 200. For example, at least a portion of the patient images(e.g., three-dimensional image dataset) may be registered to a firstpatient coordinate system (i.e., P₁ in FIG. 10) based on the firstreference marker device 1001 using a patient registration method such asdescribed above with reference to FIG. 3. In embodiments, the entirepatient image dataset may be registered to the first patient coordinatesystem, P₁. Alternately, only a portion of the patient image dataset maybe registered to the first patient coordinate system. For example, for athree-dimensional volume reconstruction image dataset, a sub-set of thevolume that is proximate to the first location 1002 on the patient 200in the axial direction may be registered to the first patient coordinatesystem.

In block 1105, at least a second portion of the patient images may beregistered to a second patient coordinate system that is based on asecond reference marker device 1003 fixed to a second location 1004 onthe patient 200. For example, at least a portion of the patient images(e.g., three-dimensional image dataset) may be registered to a secondpatient coordinate system (i.e., P₂ in FIG. 10) based on the secondreference marker device 1003 using a patient registration method such asdescribed above with reference to FIG. 3. In embodiments, the entirepatient image dataset may be registered to the second patient coordinatesystem, P₂. Alternately, only a portion of the patient image dataset maybe registered to the second patient coordinate system. For example, fora three-dimensional volume reconstruction image dataset, a sub-set ofthe volume that is proximate to the second location 1004 on the patient200 in the axial direction may be registered to the second patientcoordinate system.

In block 1107, the image-guided surgery system 400 may select betweendisplay of patient images registered to the first patient coordinatesystem and display of patient images registered to the second patientcoordinate system in the image guided surgery system 400 based onproximity to the first location 1002 and the second location 1004 on thepatient 200. In particular, the image-guided surgery system 400 maydisplay patient images that are registered to the first patientcoordinate system when the system navigates in a portion of thepatient's anatomy that is in closer proximity to the first location 1002than to the second location 1004 on the patient 200, and the imageguided surgery system 400 may display patient images that are registeredto the second patient coordinate system when the system navigates in aportion of the patient's anatomy that is in closer proximity to thesecond location 1004 than to the first location 1002 on the patient 200.

The image-guided surgery system 400 may display the patient imagesregistered to the first patient coordinate system with an overlay orsuperimposition of graphical element(s) showing the position and/ororientation of one or more objects (e.g., tool(s), instrument(s), an endeffector of a robotic arm) that are tracked by a motion tracking system105. The position and/or orientation of the one or more objects may beshown within the first patient coordinate system, which may be based onthe current position and/or orientation of the first reference markerdevice 1001 tracked by the motion tracking system 105.

The image-guided surgery system 400 may display the patient imagesregistered to the second patient coordinate system with an overlay orsuperimposition of graphical element(s) showing the position and/ororientation of the one or more objects (e.g., tool(s), instrument(s), anend effector of a robotic arm) that are tracked by the motion trackingsystem 105. The position and/or orientation of the one or more objectsmay be shown within the second patient coordinate system, which may bebased on the current position and/or orientation of the second referencemarker device 1003 tracked by the motion tracking system 105.

In embodiments, the image-guided surgery system 400 may select betweendisplay of patient images and motion tracking data in the first andsecond patient coordinate systems in response to a detected user action.For example, a user may use a pointer device 1050 (see FIG. 10) to touchthe first reference marker device 1001 or the second reference markerdevice 1003, which may cause the system 400 to select between therespective first and second patient coordinate systems. The touching ofa reference marker device 1001, 1003 by a pointer device may be detectedby the motion tracking system 105. Alternately, the system 400 mayselect between the first and second patient coordinate systems inresponse to the pointer device being moved over or touched against aportion of the patient that is closer to one reference marker devicethan to the other reference marker device. In addition, as discussedabove with reference to FIGS. 6A-6C and 7A-7C, in some embodiments theimage guided surgery system 400 may display patient images based on theposition of a robotic end effector 102 and/or a handheld display device401. In embodiments, the patient images and motion tracking data may bedisplayed in either the first patient coordinate system or the secondpatient coordinate system based on the relative proximity of the roboticend effector 102 and/or handheld display device 401 to either the firstreference marker device 1001 or the second reference marker device 1003.In further embodiments, the image-guided surgery system 400 may selectbetween display of patient images and motion tracking data in the firstand second patient coordinate systems in response to a user input at auser input device.

Embodiments of the method 1100 may provide improved accuracy and speedof image guided surgery by selectively displaying patient images andmotion tracking data (e.g., graphical depictions of tool/instrumentpose(s)) in a patient reference frame that is closest to the location ofthe surgical intervention, and therefore may more accurately representthe patient's actual situation at the time of the intervention. Multipleimage-guided surgical interventions may be performed in different areasof the patient using the same patient image dataset registered todifferent patient reference frames, without having to perform separateimage scans and/or placement of the patient reference marker betweeneach intervention, which may improve workflow and greatly reduce time insurgery.

The plurality of patient reference marker devices may also be monitoredto detect relative motion of reference marker devices during a surgicalprocedure. In optional block 1109 of method 1100, a relative motionbetween the first and second reference marker devices 1001, 1003 may bedetected by the motion tracking system 105. The detected relative motionmay indicate that a marker device 1001, 1003 is loose and/or hasaccidentally been bumped causing it to change its position relative tothe patient during a surgical procedure. The detected relative motioncould also indicate that the portion 1002 of the patient's anatomy towhich the first reference marker device 1001 is attached has movedrelative to the portion 1004 of the patient's anatomy to which thesecond reference marker device 1003 is attached. For example, therelative positions of one or more of the vertebrae between positions1002 and 1004 may have shifted during a surgical procedure. In eithercase, the relative movement of the marker devices 1001, 1003 may be ofsufficient magnitude such that one or both of the patient registrationsmay no longer accurately represent the current patient situation. Inoptional block 1111, the user may be notified (e.g., via an audibleand/or visual alert) when the detected relative motion between markers1001 and 1003 exceeds a threshold value. In some embodiments, thethreshold value may be between about 1 and 2 mm. The threshold value maybe an adjustable parameter, and in embodiments may be a function of adistance of the intended surgical site from one or both markers 1001 and1003. In some embodiments, the threshold value may be zero, such thatany relative motion between the markers 1001 and 1003 detected by themotion tracking system 105 may trigger a notification to the user.

In response to a notification that the detected relative motion betweenmarkers 1001 and 1003 exceeds a threshold value, the user may perform anupdated imaging scan and register the updated patient images registeredto the first and second patient coordinate systems as discussed above.Alternately, the user may elect to continue the procedure with thepatient images registered to one or both patient coordinate systems.

In some embodiments, the image guided surgery system 400 may determinethat a detected relative motion between reference marker devices 1001,1003 is the result of one reference marker device 1001, 1003 havingmoved with respect to the patient. For example, one of the referencemarker devices 1001, 1003 may be accidentally bumped or may become loosecausing it to move with respect to the location 1002, 1004 on thepatient 200 to which it was attached. The determination that a referencemarker device 1001, 1003 has moved may be based on a particularreference marker device 1001, 1003 moving by threshold distance and/orin a particular direction while at least one other reference markerdevice 1001, 1003 has not moved relative to the camera position of themotion tracking system 105. This may indicate that the particularreference marker device has moved with respect to the patient, asopposed to a relative movement of the portions 1002, 1004 of thepatient's anatomy to which the reference marker devices 1001, 1003 areattached. In some embodiments, the system 400 may provide a notificationto the user that one of the reference markers 1001, 1003 has moved. Theuser may verify that a particular reference marker device 1001, 1003 hasmoved using the marker devices 1001, 1003 as fiducials, as discussedabove. For example, the user may use a pointer 1050 to touch or tracethe marker devices 1001, 1003 and/or position the pointer 1050 along thetrajectories of the marker device 1001, 1003 to verify whether areference marker 1003, 1005 has moved, where a discrepancy between thelocation of the marker device 1001, 1003 measured using the pointer 1050and the location of the marker device 1001, 1003 visible in the patientimage(s) may indicate that a particular marker device 1001, 1003 hasmoved.

In some embodiments, the user may perform a registration correction whenone of the reference marker devices 1001, 1003 has moved with respect tothe patient. The registration correction may be performed withoutneeding to re-scan the patient using the imaging device 103. Forexample, the user may confirm whether the marker device 1001 that hasmoved with respect to the patient is still rigidly attached to thepatient, and may re-attach the marker device 1001 if necessary. Thetransformation of the coordinate system of the marker 1001 that hasmoved may then be adjusted so that it returns to being accurate. Thisadjustment may be based on the detected motion, including any rotationalmotion, of the reference marker device 1001 that moved with respect toone or more reference marker devices 1003 that are determined not tohave moved with respect to the patient.

FIG. 11B is a process flow diagram illustrating a further embodimentmethod 1150 for performing image-guided surgery using multiple referencemarker devices 1001, 1003 fixed to a patient and a blended orinterpolated registration of patient images. As noted above, the patientimage data set (e.g., volume data set) may depict a volume of thepatient's anatomy that does not remain rigid during a surgicalprocedure. Thus, the tracked position of a tool or instrument in apatient coordinate system based on either reference marker device 1001,1003 may lose accuracy if the patient's anatomy bends, shifts orotherwise deforms during surgery. Various embodiments may improve theaccuracy of the image-guided surgery system by displaying patient imagesand tracked tools/instruments within a blended or interpolated patientreference coordinate system that is based on multiple patient referencemaker devices fixed to different locations on a patient.

Block 1151 of method 1150 may correspond to block 1101 of method 1100,and may include obtaining patient images using an imaging device, suchas imaging device 103. In block 1153, a motion tracking system 105 maytrack a first reference marker device 1001 fixed to a first location1002 on the patient and a second reference marker device 1003 fixed to asecond location 1004 on the patient. In the example of a spinal surgery,for instance, the first reference marker device 1001 may be fixed to afirst location 1002 on a first vertebral level of the patient's spine,and the second reference marker device 1003 may be fixed to a secondlocation 1004 on a second vertebral level of the patient's spine.

In block 1155, the image-guided surgery system 400 may display one ormore patient images corresponding to a third location of the patient ina blended or interpolated patient reference coordinate system based ontracking data for both the first reference marker device 1001 and thesecond reference marker device 1003. The patient images may be displayedwith an overlay or superimposition of graphical element(s) showing theposition and/or orientation of the one or more objects (e.g., tool(s),instrument(s), an end effector of a robotic arm) that are tracked by themotion tracking system 105, where the one or more objects may be shownwithin the blended or interpolated patient coordinate system. The thirdlocation of the patient may be, for example, an intervening vertebrallevel between the vertebral levels to which the first and secondreference marker devices 1001, 1003 are attached. The patient image(s)corresponding to the third location may include one or more axial slicesof the intervening vertebral level from a three-dimensional dataset(e.g., a 3D CT reconstruction).

In embodiments, the patient image(s) and instrument/tool pose(s) may bedisplayed in a blended or interpolated reference coordinate system thatmay be weighted by distance from the first and second reference markerdevices 1001, 1003. Other interpolation (i.e., weighting) techniques maybe utilized. In some embodiments, the blended or interpolated referencecoordinate system may be may be based, at least in part, on amathematical and/or physical modeling of the anatomical feature ofinterest. In one example, the patient's spine may be modeled using acubic spline interpolation, where a set of control points for the splinemay be defined with reference to the vertebral levels of interest in thescan data. At least two of the control points of the spline may bedefined with reference to the first and second reference marker devices1001, 1003, which may be fixed to different vertebral levels of thepatient's spine. This may enable these control points to be tracked bythe motion tracking system 105 during surgery. A fitting algorithm maybe used to estimate a change in position and/or orientation of anintervening vertebral level during surgery based on a detected change inthe relative positions of the control points tracked using the motiontracking system 105. Such an estimate may be used by the image-guidedsurgery system 400 to generate a correction factor for the display ofpatient image(s) and tool/instrument pose(s) in a blended orinterpolated patient reference coordinate system. In furtherembodiments, the physical structure of the anatomy of interest may bemodeled based on an analysis of the image data. For example, in the caseof a spine procedure, the structure of the patient's spine, includingthe physical relationship of each of the vertebral levels of interest,and optionally the various motions (e.g., bending, torsional movements,compression and/or stretching) of the patient's spine, may be modeledbased on an analysis of the patient image data set (e.g., CT data). Thismodeling may be used in conjunction with the tracked position of each ofthe patient reference marker devices 1001, 1003 to generate suitablecorrection(s) for display of patient images and tool poses in a blendedor interpolated patient reference coordinate system during a surgicalprocedure.

FIG. 11C illustrates a further embodiment method 1160 for performingimage-guided surgery using multiple reference marker devices 1001, 1003fixed to a patient. Block 1161 of method 1160 may correspond to block1101 of method 1100, and may include obtaining patient images using animaging device, such as imaging device 103. In block 1163, the patientimages may be registered to a patient coordinate system using a patientregistration method, such as described with reference to FIG. 3. In someembodiments, the patient images may be registered to multiple patientcoordinate systems based on respective first and second reference markerdevices 1001 and 1003, such as described above with reference to FIG.11A. In block 1165, patient image(s) and tool/instrument pose(s) may bedisplayed in a patient reference coordinate system. The patientreference coordinate system may be based on the tracked position one ofthe first and second reference marker devices 1001, 1003, as describedwith reference to FIG. 11A or may be displayed in a blended orinterpolated coordinate system based on the tracked positions of both ofthe reference marker devices 1001, 1003, as described with reference toFIG. 11B.

In block 1167, a motion tracking system 105 may detect a relative motionbetween the first reference marker device 1001 fixed to a first location1002 on the patient and a second reference marker device 1003 fixed to asecond location 1003 on the patient. As discussed above, a relativemotion between reference marker devices 1001, 1003 may be due to ashifting of the patient's anatomy during surgery (e.g., a bending,twisting, compression and/or stretching of the spine in the case of aspine surgery) or may be the result of a movement of a reference markerdevice 1001, 1003 moving with respect to the patient. Either case mayresult in a loss in registration accuracy. However, typically a greaterloss in registration accuracy will result from a reference marker devicemoving with respect to its attachment point on the patient, such as byan accidental bumping, than through a natural movement of the patient'sanatomy.

In determination block 1069, the image guided surgery system 400 maydetermine whether the detected motion of the reference marker devices1001, 1003 is consistent with an anatomic movement. In other words, thesystem 400 may determine whether the detected motion is more likely dueto a shift in the anatomy during surgery or due to a movement of areference marker device 1001, 1003 relative to the patient. Thedetermination may be based on a software model of the anatomical regionof interest (e.g., a spine) and/or may be based on a set ofpre-determined boundary conditions which may define the possible orlikely movements of the anatomy that may occur during the surgicalprocedure. In one non-limiting example, the system 400 may determinethat a particular detected movement of the reference marker devices1001, 1003 is not consistent with an anatomic movement when the detectedmotion corresponds to a movement that is not anatomically possible(e.g., would result in too great of a bend radius in the case of a humanspine, would result in a superimposition of multiple rigid structures,such as vertebrae, etc.). In response to determining that that thedetected motion is not consistent with an anatomic movement (i.e.,determination block 1069=“No”), the system 400 may notify the user(e.g., via an audible and/or visual alert) in block 1171. Thenotification may indicate that one of the reference marker devices 1001,1003 has likely moved and that the registration may no longer besufficiently accurate.

In response to determining that the detected motion is consistent withan anatomic movement (i.e., determination block 1069=“Yes”), the system400 may update the display of the patient image(s) and tool pose(s)based on an estimation of the anatomic movement corresponding to thedetected relative motion of the reference marker devices 1001 and 1003in block 1173. The estimate may be determined using a mathematic and/orphysical model of the anatomic feature of interest (e.g., the vertebrallevels of the spine) as described above with reference to FIG. 11B.

FIG. 12 is a system block diagram of a computing device 1300 useful forperforming and implementing the various embodiments described above. Thecomputing device 1300 may perform the functions of an image guidedsurgery system 400, for example. While the computing device 1300 isillustrated as a laptop computer, a computing device providing thefunctional capabilities of the computer device 1300 may be implementedas a workstation computer, an embedded computer, a desktop computer, aserver computer or a handheld computer (e.g., tablet, a smartphone,etc.). A typical computing device 1300 may include a processor 1301coupled to an electronic display 1304, a speaker 1306 and a memory 1302,which may be a volatile memory as well as a nonvolatile memory (e.g., adisk drive). When implemented as a laptop computer or desktop computer,the computing device 1300 may also include a floppy disc drive, compactdisc (CD) or DVD disc drive coupled to the processor 1301. The computingdevice 1300 may include an antenna 1310, a multimedia receiver 1312, atransceiver 1318 and/or communications circuitry coupled to theprocessor 1301 for sending and receiving electromagnetic radiation,connecting to a wireless data link, and receiving data. The computingdevice 1300 may also include a camera 1320 coupled to the processor 1301for obtaining photographs and/or video images that may optionally beshown on the display 1304. A handheld computing device (e.g., a tablet,smartphone) may include camera 1320 in a rear-facing configuration fordisplay of real-time video images as discussed above in connection withFIGS. 7D and 7E. Additionally, the computing device 1300 may includenetwork access ports 1324 coupled to the processor 1301 for establishingdata connections with a network (e.g., LAN coupled to a service providernetwork, etc.). A laptop computer or desktop computer 1300 typicallyalso includes a keyboard 1314 and a mouse pad 1316 for receiving userinputs.

The foregoing method descriptions are provided merely as illustrativeexamples and are not intended to require or imply that the steps of thevarious embodiments must be performed in the order presented. As will beappreciated by one of skill in the art the order of steps in theforegoing embodiments may be performed in any order. Words such as“thereafter,” “then,” “next,” etc. are not necessarily intended to limitthe order of the steps; these words may be used to guide the readerthrough the description of the methods. Further, any reference to claimelements in the singular, for example, using the articles “a,” “an” or“the” is not to be construed as limiting the element to the singular.

The various illustrative logical blocks, modules, circuits, andalgorithm steps described in connection with the embodiments disclosedherein may be implemented as electronic hardware, computer software, orcombinations of both. To clearly illustrate this interchangeability ofhardware and software, various illustrative components, blocks, modules,circuits, and steps have been described above generally in terms oftheir functionality. Whether such functionality is implemented ashardware or software depends upon the particular application and designconstraints imposed on the overall system. Skilled artisans mayimplement the described functionality in varying ways for eachparticular application, but such implementation decisions should not beinterpreted as causing a departure from the scope of the presentinvention.

The hardware used to implement the various illustrative logics, logicalblocks, modules, and circuits described in connection with the aspectsdisclosed herein may be implemented or performed with a general purposeprocessor, a digital signal processor (DSP), an application specificintegrated circuit (ASIC), a field programmable gate array (FPGA) orother programmable logic device, discrete gate or transistor logic,discrete hardware components, or any combination thereof designed toperform the functions described herein. A general-purpose processor maybe a microprocessor, but, in the alternative, the processor may be anyconventional processor, controller, microcontroller, or state machine. Aprocessor may also be implemented as a combination of computing devices,e.g., a combination of a DSP and a microprocessor, a plurality ofmicroprocessors, one or more microprocessors in conjunction with a DSPcore, or any other such configuration. Alternatively, some steps ormethods may be performed by circuitry that is specific to a givenfunction.

In one or more exemplary aspects, the functions described may beimplemented in hardware, software, firmware, or any combination thereof.If implemented in software, the functions may be stored on as one ormore instructions or code on a non-transitory computer-readable medium.The steps of a method or algorithm disclosed herein may be embodied in aprocessor-executable software module executed which may reside on anon-transitory computer-readable medium. Non-transitorycomputer-readable media includes computer storage media that facilitatestransfer of a computer program from one place to another. A storagemedia may be any available media that may be accessed by a computer. Byway of example, and not limitation, such non-transitorycomputer-readable storage media may comprise RAM, ROM, EEPROM, CD-ROM orother optical disk storage, magnetic disk storage or other magneticstorage devices, or any other medium that may be used to carry or storedesired program code in the form of instructions or data structures andthat may be accessed by a computer. Disk and disc, as used herein,includes compact disc (CD), laser disc, optical disc, digital versatiledisc (DVD), floppy disk, and blu-ray disc where disks usually reproducedata magnetically, while discs reproduce data optically with lasers.Combinations of the above should also be included within the scope ofnon-transitory computer-readable storage media. Additionally, theoperations of a method or algorithm may reside as one or any combinationor set of codes and/or instructions on a machine readable medium and/orcomputer-readable medium, which may be incorporated into a computerprogram product.

The preceding description of the disclosed aspects is provided to enableany person skilled in the art to make or use the present invention.Various modifications to these aspects will be readily apparent to thoseskilled in the art, and the generic principles defined herein may beapplied to other aspects without departing from the scope of theinvention. Thus, the present invention is not intended to be limited tothe aspects shown herein but is to be accorded the widest scopeconsistent with the principles and novel features disclosed herein.

1. A method of displaying image data, comprising: displaying image dataof a patient on a display screen of a handheld display device; trackingat least one of a position and an orientation of the handheld displaydevice with respect to the patient; and modifying at least a portion ofthe image data displayed on the display screen in response to a changein at least one of the position and orientation of the handheld displaydevice with respect to the patient.
 2. The method of claim 1, whereinthe image data comprises a portion of a three-dimensional dataset of thepatient's anatomy, the three-dimensional dataset comprises at least oneof an x-ray computed tomography (CT) reconstruction and a magneticresonance (MR) image data.
 3. (canceled)
 4. The method of claim 2,wherein displaying image data on the display screen of the handhelddisplay device comprises: determining at least one of a first positionand a first orientation of the handheld display device with respect tothe patient; and displaying a first portion of the three-dimensionaldataset of the patient's anatomy on the display screen based on thedetermined a least one of the first position and the first orientationof the handheld computing device.
 5. The method of claim 4, whereindisplaying the first portion of the three-dimensional dataset comprisesdisplaying at least one two-dimensional slice of the three-dimensionaldataset of the patient's anatomy in at least one first plane defined bythe first position and/or orientation of the handheld display devicewith respect to the patient, and modifying at least a portion of theimage data displayed on the display screen comprises displaying the atleast one two-dimensional slice of the three-dimensional dataset of thepatient's anatomy in at least one second plane defined by a detectedsecond position and/or orientation of the handheld display device withrespect to the patient.
 6. The method of claim 5, wherein at least oneof: (i) the at least one two-dimensional slice comprises at least one ofan axial, sagittal and coronal slice of the patient's anatomy; and (ii)the at least one two-dimensional slice comprises a coronal slice in aplane offset from the handheld display device by a pre-determineddistance.
 7. (canceled)
 8. The method of claim 4, wherein displaying thefirst portion of the three-dimensional dataset comprises displaying athree-dimensional rendering of the patient's anatomy in a first viewbased on the first position and/or orientation of the handheld displaydevice with respect to the patient, and modifying at least a portion ofthe image data displayed on the display screen comprises displaying thethree-dimensional rendering of the patient's anatomy in a second viewbased on a detected second position and/or orientation of the handhelddisplay device with respect to the patient.
 9. The method of claim 1,wherein at least one of: (i) the handheld display device comprises atleast one of a tablet computer, a smartphone and a pendant controller,and (ii) the method further comprises displaying the image data of thepatient on a second display screen.
 10. (canceled)
 11. The method ofclaim 2, further comprising: displaying a second image of the patientobtained by a camera on the handheld display device on the displayscreen, wherein the portion of a three-dimensional dataset of thepatient's anatomy is displayed overlaying the second image.
 12. Themethod of claim 11, wherein at least one of: (i) the second imagecomprises a real-time video image of the patient, and (ii) the portionof the three-dimensional dataset comprises a three-dimensional volumerendering of a portion the patient's anatomy visible in the secondimage.
 13. (canceled)
 14. The method of claim 12, wherein the portion ofthe three-dimensional dataset comprises a three-dimensional volumerendering of a portion the patient's anatomy visible in the secondimage, and the method further comprises performing a calibration processto match the three-dimensional volume rendering to the view of thepatient in the second image.
 15. The method of claim 14, furthercomprising updating the three-dimensional volume rendering based on achange in the position of the camera relative to the patient.
 16. Themethod of claim 15, further comprising adjusting a transparency of thethree-dimensional volume rendering relative to the second image on thedisplay device in response to a user input.
 17. A method of displayingimage data, comprising: displaying image data of a patient on a displayscreen; tracking at least one of a position and an orientation of an endeffector of a robotic arm with respect to the patient; and modifying atleast a portion of the image data displayed on the display screen inresponse to a change in at least one of the position and orientation ofthe end effector with respect to the patient.
 18. A sterile case for ahandheld display device, comprising: a first portion defining a firstsurface of the case, the first portion comprising a window region in thefirst surface that is sized and shaped to correspond to a display screenof a handheld display device; a second portion defining a second surfaceof the case opposite the first surface, the first portion and the secondportion defining a housing for receiving a handheld display device, thefirst and second portions having corresponding mating features that areengaged to secure a handheld display device within the housing; aplurality of markers mounted to at least one of the first portion andthe second portion and disposed in a pre-determined geometric pattern toenable at least one of the position and the orientation of the case tobe tracked by a motion tracking system, the first portion and the secondportion having sufficient rigidity to prevent relative movement of theplurality of markers.
 19. The sterile case of claim 18, wherein thewindow region comprises a substantially flat and rigid area of the firstportion configured to lie flat adjacent to the display screen of thehandheld display device and the window region enables touchscreenfunctionality of the handheld display device through the window region.20. (canceled)
 21. The sterile case of claim 18, wherein at least oneof: (i) the markers comprise spherically-shaped reflectors locatedwithin pockets formed by at least one of the first portion and thesecond portion, (ii) the pre-determined geometric pattern of markers isasymmetric such that the pattern is different when viewed from the frontand back sides of the case, (iii) the sterile case further comprises asecondary enclosure member that is slidable over the first portion andthe second portion on a periphery of the case to secure the firstportion and the second portion, (iv) the case has a clamshellconfiguration with the first portion and the second portion connected bya hinge portion, and (v) the second surface of the case comprises atleast one of a handle portion and a feature for mating with a supportelement for the case.
 22. (canceled)
 23. The sterile case of claim 18,further comprising a secondary enclosure member that is slidable overthe first portion and the second portion on a periphery of the case tosecure the first portion and the second portion, wherein the secondaryenclosure member comprises a latch portion for removably mounting thecase to a support element. 24-26. (canceled)
 27. A display device for arobotic arm, comprising: (i) a contoured viewing surface that extendsaround at least 50% of an outer periphery of a linkage member of therobotic arm, the display device displaying image data of a patient onthe viewing surface.
 28. The display device of claim 27, wherein atleast one of: (i) the display device further displays system informationfor the robotic arm, (ii) the display device comprises a plurality ofdisplay tiles forming the viewing surface, the plurality of displaytiles being angled to approximate a contour of the outer periphery ofthe linkage member, and (iii) the display device comprises a curveddisplay.
 29. (canceled)
 30. (canceled)
 31. The display device of claim27, further comprising: a controller operatively coupled to the displaydevice and configured to detect a rotational motion of the displaydevice with respect to a viewing position and modify at least one imageshown on the display device in response to the detected rotationalmotion.
 32. The display device of claim 31, wherein the controller isconfigured to maintain at least one image on the display surface suchthat it remains visible from the viewing position while the displaydevice rotates.
 33. (canceled)
 34. (canceled)
 35. A method forperforming image-guided surgery using multiple reference marker devicesfixed to a patient, the method comprising: obtaining patient imagesusing an imaging device; registering at least a first portion of thepatient images in a first patient coordinate system associated withfirst reference marker device fixed to a first location on the patient;registering at least a second portion of the patient images to a secondpatient coordinate system associated with a second reference markerdevice fixed to a second location on the patient; and selecting betweendisplay of patient images registered to the first patient coordinatesystem and display of patient images registered to the second patientcoordinate system in an image guided surgery system based on a proximityto the first and second locations.
 36. The method of claim 35, furthercomprising: detecting a relative movement between the first and secondreference marker devices; and notifying a user when the detectedrelative movement is greater than a threshold value.
 37. The method ofclaim 35, further comprising: verifying the patient image registrationsto determine whether a reference marker device has moved relative to thepatient, wherein the first reference marker device and the secondreference marker device are visible in the patient images, and thepatient image registrations are verified using at least one of the firstreference marker device and the second reference marker device as afiducial; and performing a registration correction in response todetermining that a reference marker device has moved relative to thepatient.
 38. (canceled)
 39. The method of claim 37, wherein theregistration correction is performed without re-scanning the patient toobtain additional patient images.
 40. A method for performingimage-guided surgery using multiple reference marker devices fixed to apatient, the method comprising: obtaining patient images using animaging device; tracking a first reference marker device fixed to afirst location on the patient and a second reference marker device fixedto a second location on the patient using a motion tracking system; anddisplaying one or more patient images corresponding to a third locationon the patient and a graphical depiction of a pose of an object trackedby the motion tracking system based on tracking data for both the firstreference marker device and the second reference marker device in animage-guided surgery system.
 41. The method of claim 40, wherein atleast one of: (i) the first and second locations on the patient arelocated on first and second vertebral levels of the spine and the thirdlocation corresponds to an intervening vertebral level between the firstand second vertebral levels, and (ii) the patient images of the thirdlocation and the graphical depiction of the pose of the object aredisplayed in a blended or interpolated patient coordinate system basedon the tracking data for the first reference marker device and thesecond reference marker device.
 42. (canceled)
 43. The method of claim41, wherein the patient images of the third location and the graphicaldepiction of the pose of the object are displayed in a blended orinterpolated patient coordinate system based on the tracking data forthe first reference marker device and the second reference markerdevice, and wherein at least one of: (i) the patient images of the thirdlocation and the graphical depiction of the pose of the object aredisplayed in a blended or interpolated patient coordinate system that isweighted by distance from the first reference marker device and thesecond reference marker device, and (ii) the blended or interpolatedpatient reference coordinate system is based on a mathematical and/orphysical modeling of the anatomical feature of interest.
 44. (canceled)45. The method of claim 43, wherein the blended or interpolated patientreference coordinate system is based on a mathematical and/or physicalmodeling of the anatomical feature of interest, and the model comprisesa spline interpolation having control points that are defined withreference to the first and second reference marker devices, and whereinthe control points are tracked using the motion tracking system toestimate a change in the position and/or orientation of the thirdlocation during a surgical procedure and the patient images of the thirdlocation and the graphical depiction of the pose of the object displayedby the image-guided surgery system are adjusted based on the estimatedchange.
 46. (canceled)
 47. A method for performing image-guided surgeryusing multiple reference marker devices fixed to a patient, the methodcomprising: obtaining patient images using an imaging device;registering patient images to a patient coordinate system; displayingthe patient images and a graphical depiction of a pose of an objecttracked by a motion tracking system in the patient coordinate systemusing an image-guided surgery system; detecting a relative motionbetween a first reference marker device fixed to a first location on thepatient and a second reference marker device fixed to a second locationon the patient using the motion tracking system; determining whether thedetected relative motion is consistent with an anatomic movement; andupdating the display of the patient images and the graphical depictionof the pose of the object based on an estimation of the anatomicmovement in response to determining that the detected relative motion isconsistent with an anatomic movement.
 48. The method of claim 47,further comprising: notifying a user in response to determining that thedetected relative motion is not consistent with an anatomic movement.49. (canceled)